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SCIENCE & MEDICINE DEPX, ^^^

THE

JOHNS HOPKINS HOSPITAL

BULLETIN

VOLUME XII

BALTIMORE
THE JOHNS HOPKINS PRESS
1901

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PRINTED BY

^(i« ;^rici)«nnjafi Company

BALTIMORE, MD., U. S. A.

VI 3.

BULLETIN

THE JOHNS HOPKINS HOSPITAL.

Vol. Xll.-No. 118.]

BALTIMORE. JANUARY. 1901.

[Price, 15 Cents.

CONTENTS.

PAGE

The Removal of Pelvic Inflammatory Masses by the Abdomen after

Bisection of the Uterus. By Howard A. Kelly, M. D., . . 1

Abstract. Tlie Bacteriology of Cystitis, Pyelitis and Pyelonephritis

in Women. By Thomas R. Buown, M. D., 4

The Intrinsic Blood- Vessels of the Kidney and their Signirtcauce in

Nephrotomy. By Max Brodel, 10

Notes on jiC.obic Spore-Bearing Bacilli. By \V. W. Foud, M. D.,
r^.t.R., 13

Summaries or Titles of Papers by Members of the Hospital and

Medical School Staff Appearing Elsewhere than in the Bulletin, 16

Proceedings of Societies:

The Johns Hopkins Hospital Medical Society, 17

Case 5of Asthma with Cyanosis, Extensive Purpura, Painful
Muscles, and Eosinophilia [Dr. Osler] ; — Bisection of the Uterus
in Hysterectomy [Dr. Kelly] ;— Exhibition of Surgical Cases

PAQK

[Dr. Mitchell]; — Report of Cases from the Garrett Hospital
for Children [Dr. Platt] ; — The Relation of Cholelithiasis to
Disease of the Pancreas and to Fat-Necrosis [Dr. Opie]; —
Secondary Syphilitic Eruption [Dr. Futcher] ; — Observations
on Blood in Typhoid Fever [Dr. Thayer]; — Albumosuria
[Dr. HAMBnRGEK]; — Exhibition of Pathological Specimens:
Vegetative Endocarditis, Cystic Kidney, Carcinoma of Gall-
Bladder [Dr. Marshall]; — Congenital Absence of Pectoralis
Major and Minor [Dr. Rosk] ; — Report of Gynsecological Cases
[Dr. Miller] ; — Demonstration of a New Hemoglobinometer
[Dr. Dare]; — Cirrhosis of the Stomach [Dr. McCrae]; — Ab-
dominal Tumor containing a Dermoid Cyst [Dr. Mitchell] ; —
Two Cases of Acute Pancreatitis [Dr. Bloodgood] ; — Tuber-
culosis of the Aorta [Mr. Longcope].

Notes and News, 38

Notes on New Books, 29

Books Received, 30

THE REMOVAL OF PELVIC INFLAMMATORY MASSES BY THE ABDOMEN AFTER

BISECTION OF THE UTERUS.^

By Howard A. Kelly, M. D.

I pointed out but recently (Johns Hopkins Hospital
Bulletin, 1900, XI, p. 56, and Amer. Jour. Ohst., 1900;
XLII, August) the great advantages which accrue from the
bisection of the myomatous uterus in an abdominal enuclea-
tion in certain complicated cases. I now desire to call your
attention to the great value of a somewhat similar pro-
cedure in certain cases of pelvic inflammatory diseases.

In most instances of pelvic infections, the ovaries are
innocently, only accidently, involved in the inflammatory
process, and as a rule one or both of them can be saved even
though it is found necessary to sacrifice both uterine tubes.
If one ovary is saved, the uterus must also be saved if pos-

■ An address delivered before The Southern Surg. & Gyn. Assoc,
Atlanta, Ga., November 13, 1900.

sible, as by doing this we conserve the function of men-
struation as well as that of internal secretion of the ovary.

Where the ovaries are seriously involved in the disease,
where they are converted into abscess sacs or into large
hematomata, or where they are so densely and intimately
matted in with the inflamed tubes that it is useless to
attempt to save them, the removal of all the diseased organs
together with the uterus is demanded wheneve - it is possible
in this way: by freeing the tube and the ovary on the least
adherent side first, and then after tying off the broad liga-
ment and pushing down the bladder, and securing the uterine
artery, the most difficult side is easily reached and enu-
cleated, by cutting across the cervix and exposing the oppo-
site uterine vessels and ligating them. The uterus is -then
pulled up until the round ligament is caught and divided.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

At this point the operation may follow one of two courses
according to the difRciilties encountered: in the iii-st place,
if, after dividing the uterus and pulling it up, the remaining
tube and ovary can be readily enucleated by peeling them
out from below upwards by working with the fingers in the
lower and anterior part of the pelvis, then the enucleation
may be concluded by removing all the structures in one mass.
In the second place, if the tube and ovary on the far side
are densely adherent and offer any serious difficulties in the
enucleation, then I would clamp off the uterus at its cornu
and remove it with one tube and ovary, and so leave the more
difficult side to be dissected out after emptying the pelvis,
securing all the advantages of increased space and light
(v. Figs. 1 and 2). I have previously described this method
as that of enucleation by a continuous transverse incision
from left to right or from right to left.

Fig. 1 shows the method of removing the uterus, in a case of pelvic
inflammatory disease, by a continuous transverse incision beginning on
the left side.

1 controls the left ovarian vessels.

2 controls the left round ligament; the next step Is to free the vesical
peritoneum from the uterus and to push the bladder down ; this exposes
the left uterine vessels which are now controlled by o.

4 represents the division of the cervix exposing the right uterine ves-
sels controlled by n.

The division of the cervix is not directly across, a sliver or a snipe
(4 to 6), is left in order to clamp the uterine vessels at a higher point.

6 is the ligature on the right round ligament and 7 that on the right
ovarian vessels.

It is now my desire to describe a method of enucleation
through an abdominal incision which is applicable to a class
of cases still more difficult than those just referred to. I^et
us suppose, for example, a case in which there are pelvic
abscesses on both sides densely adherent to all the surrounding
structures, including the uterus; we will also suppose that
the uterus itself is almost or quite buried in a mass of adhe-
sions. In such a case the plan I have just described is
scarcely applicable, inasmuch as there is no easier side on
which to begin to start the enucleation, for both sides pre-
sent extreme difficulties.

The method of a continuous transverse incision does actu-
ally give us, it is true, a great advantage over the older
method of tying down on both sides, for the simple reason
that the enucleation of the farther side, wherever we begin,
is always easier, even though the difficulties of the first side
are just the same by either method.

If, now, I could devise any method by which the enuclea-
tion of both tubes and ovaries in such a case could be effected
in a direction from below upwards, it is manifest that a great
advantage would be gained.

The vaginal hysterectomists have thus far had a decided
advantage over those of us who prefer to operate above the
symphysis, in the greater facility with which the adherent
structures can be detached when they are attacked in the
direction from the pelvic floor upwards. In the method I
am now about to describe, this decided advantage is secured

Fig. 3 shows an important modification of the method of enucleation
described and shown in Fig. 1. When one side is densely adherent, it is
best then to begin the enucleation with the opposite side in the order
already described, and then after tying the round ligament at 0.

The next step then is to clamp the cornu uteri and remove the uterus
with the tube and ovary of the side on which the enucleation was
started.

The final step in the enucleation now is to remove the densely
adherent side with forceps and scissors with all the advantages of
abundant room and light afforded by the removal of the uterus.

for, and combined with the other great advantages of the
abdominal route, that of increased room, and increased facil-
ities of handling, abundant illumination, as well as the
detection of various complicating conditions.

The steps are these: If the uterus is buried out of view,
the bladder is first separated from the rectum and the fundus
uteri found; then, if there are any large abscesses, adherent
cysts, or hematomata, they are evacuated by aspiration or
by puncture; the rest of the abdominal cavity is then well
packed off from the pelvis.

The right and left cornua uteri are each seized by a pair
of stout museau forceps and lifted up, the uterus is now
incised in the median line in an antero-posterior direction,

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE I.

Fir., a shows the advaiitasics of :i bisection of the uterus euabling the surs:eon to remove the uterus before removing either
tube and ovary, thus atl'ording all the conveniences of more room, abundant illumination and new avenues of approach
indicated by the arrows.

Ligatures may be placed on tlie ovarian vessels as shown before cuucleatinir the uterine tubes .and the ovaries, when the
vessels are accessible.

'ecMi^'r/ce

Fig. 4 shows the first step in the bisection of an adherent n^trotlexed uterus. The forceps catch the anterior face which is
opened, then the bladder is |pushed down and the cervix divided Injin side to side as indicated by the arrows.

rfi

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE II.

Fig. .5. — After freeiuy; the cer\ix
directiou from below up.

from its vaglniil end it is held up and the bisettiun cuuiijlrtnl as shown here, iu a

Fig. 0 shows the bisection conipU'ted. Eaeh half of the uterus is now removed b.v uiiiilyin;;: ligatures as indieated by tin'
arrows on tlie round liganieuts and the uterine cornua. The lateral iutlauiniatory masses are remo^'ed last of all.

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

and as the uterus is bisected, its eornua are pulled up and
drawn apart. With a third pair of forceps the uterus f=
grasped on one side on its cut surface, as far down in the
angle as possible, includiiTg both anterior and posterior walls.
The museau forceps of the same side is then released and
used for grasping the corresponding point on the opposite
cut surface, when the remaining inuseau forceps is removed.
In this way two forceps are in constant use at the lowest
point. I commonly apply them three or four times in all
As the uterus ig pulled up the halves become everted and
it is bisected further down into the cervix; if the oper-
ator prefers to do a pan-hysterectomy, the bisection is car-
ried all the way down into the vagina. The uterine canal
must be followed in the bisection, if necessary using a
grooved director to keep it in view. The museau forceps are
now made to grasp the uterus well down in the cervical por-
tion, if it is to be a suprn-vaginal amputation, and the cervi.^
is divided on one side. As soon as it is severed and the
uterine and vaginal ends begin to pull apart, the under
surface of the uterine end is caUght with a pair of forceps
and pulled up and the uterine vessels, which can now be
plainly seen, are clamped or tied. As the uterus is pulled
still further up, the round ligament is exposed and clamped,
then finally a clamp is applied between the cornu of the
bisected uterus and the tubo-ovarian mass, and one-half of
the uterus is removed. The opposite half of the uterus is
also taken away in the same manner.

The pelvis now contains nothing but rectum and bladder,
with right and left tubo-ovarian masses plastered to the sides
of the pelvis and the broad ligaments, affording abundant
room for investigation of their attachments, as well as for
deliberate and skillful dissection; the wide exposure of the
cellular area over the inferior median and anterior surfaces
of the masses, offers the best possible avenue for beginning
their detachment and enucleation.

The operator will sometimes find on completing the bi-
section of the uterus that he can just as well take out each
tube and ovary together with its corresponding half of the
uterus, reserving for the still more difficult cases, or for a
most difficult side, the separate enucleation of the tube and
ovary after removal of the uterus.

The operation which I have just described is not recom-
mended to a beginner in surgery; the surgeon who under-
takes it must be calm and deliberate, and must bear in mind
at each step the anatomical relations of the structures.

The most critical point is the bisection of the cervix and
controlling the uterine vessels; if the cervix is slowly and
■cautiously severed with a steady traction on the uterus under
perfect control, there is no danger of seeing the organ sud-
denly tearing out with rupture of the uterine vessels and
frightful hemorrhage. As the divided cervix is pulled apart,
the uterine vessels are beautifully exposed and easily caught,
only a clumsy operator will plunge his needle or a pair of
forceps deep down into the tissues and clamp a ureter. By
cutting up the cervix so as to leave a snipe on each side the
uterine vessels can be caught at a higher level than that
of the division of the cervix.

There is no danger of injuring the bladder, which needs
less attention than in any other method of hysterectomy;
when the bisection reaches the vesico-uterine fold it may bo
continued carefully behind this fold well down into the
cervix under the bladder which is then easily pushed down
as the divided cervix is pulled apart. A simple and a safe
way is also to incise the vesico-iiterine peritoneum from side
to side and push it down with a sponge on a staff and so
bare the cervix.

If the uterus is densely adherent to the rectum all the
way up to the fundus, a modification of this plan of operat-
ing may be followed; the anterior face of the uterus may be
bisected and the cervix divided horizontally and the uterine
vessels caught, then the rest of the uterus may be carefully
divided up its posterior surface in a direction from the
cervix towards the fundus. The relations to the rectum are
examined as the division is made, and at any point where it
seems nccessar)', a piece of the uterine tissue may be left
adherent to the bowel. After the bisection the rest of the
enucleation is effected as described above.

I have had abundant opportunity to demonstrate the prac-
tical value of this method of treatment in my clinic this year.

In one case (Ward H, 12 April, 1900) the uterus, tubes
and ovaries were so densely adherent that an effort to free them
by the vaginal route failed when I opened the abdomen and
caught the uterus by its eornua and bisected it half way
down the cervix, and then removed each half uterine body,
then with a maximum space under sight and touch the tubes
and ovaries were dissected out.

In another instance (W., 5 May, 1900) the entire uterus
was bisected and removed and after its removal a large pelvic
abscess was extirpated on the right side.

In a case operated upon 7 Nov., 1900 (W., H) the sigmoid
on the left and the rectum on the right were the seat of
fistulous openings into the uterine tubes. Here the fistulse
and other complications did not have to be treated until the
uterus was divided and brought out into the surface.

Another patient in my private hospital had tubercular
disease of both tubes (S., April, 1900), which was extirpated
with bisection of the uterus.

In one instance (B., 17 Oct., 1900) there were extensive
hematomata of both ovaries with dense adhesions and a most
difficult enucleation was rendered safe by bisection.

In a case of a large cancerous right ovary (B., l9 May,
1900), extending into the pelvic cellular tissue, I found a
bisection most helpful in clearing out the pelvis and exposing
the disease on its median and under sides, and so making
possible a much completer enucleation.

The dangers of the method are those of any novel pro-
cedure, and must arise for the most part from want of due
attention to the details; for example, one can by reckless
cutting divide the uterus obliquely so as to cut directly' into
the broad ligament among the uterine vessels instead of
following the uterine canal and making a true coronal
section. Again, rashly cutting, one can divide one-half of
the cervix and divide the uterine vessels at the same time
with frightful hemorrhage; by clamping the bleeding uterine

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

vessels in an indiscriminate fashion the nreter may be easily
included in the clamp.

I suppose, too, that it is easily possible with sufficient care-
lessness to cut a hole in the bladder.

The risk of sepsis from opening the uterine cavity is prac-
tically nil if gauze is packed in around the uterus; further-
more the study of many of these uteri has shown that the
infection rarely ever lingers in its cavity.

The advantages of a bisection and enucleation of the
uterus as a preliminary to a complete enucleation of uterine
tubes and ovaries for pelvic inflammatory and other diseases
by the abdominal route are briefly recapitulated:

1. Additional space for handling adherent adnexte, af-
forded by the removal of the uterus.

2. Great increase in facility for dealing with intestinal
complications.

3. Better access by new avenues from below and in front
to adherent lateral structures.

4. Elevation of structures to or above pelvic brim or even
out into the abdomen, bringing them within easy reach of
manipulation and dissection.

5. The same advantage in approaching both uterine vessels
by cutting from cervix out towards the broad ligaments as is
secured in approaching one of them in the continuous trans-
verse incision method.

In general, the time of the operation is shortened; its
steps are conducted with greater precision; siirrounding
structures are far less liable to be injured. In this way
there are fewer troubles and sequelae and the mortality is
lessened.

I take it that in intraligamentary tumors of both sides this
procedure will prove of the utmost advantage in exposing
the tumors at a point low down in the loose cellular tissue
of the broad ligament.

I have found since writing this that a similar plan of oper-
ating has been advocated by J. L. Faure of Paris.

ABSTRACT.'

THE BACTERIOLOGY OF CYSTITIS, PYELITIS AND PYELONEPHRITIS IN WOMEN.

By Thomas E. Brown, M. D.,
Assistant Physician The Johns Hopkins Hospital Dispensarij.

It is only within very recent years that the bacteriological
nature of the infections of the urinary tract has been placed
upon a firm basis by the work of Eovsing, Melchior, Guyon,
Krogius, Schnitzler, Albarran and Halle and others, and
there are still many questions regarding this subject which
have not been answered, and various contentions which have
not been settled.

The objects of my research have been to determine defi-
nitely, as far as lay in my power, the bacterial flora of the
infections of the urinary tract in women and to clear up, as
far as possible, the moot questions in this subject, to discuss
the other factors which may play a part in the etiology of
such infections and their relative importance in the develop-
ment of these conditions, to determine the various modes of
entrance of the bacteria into the urinary apparatus, to
formulate if possible certain rules regarding the relationship
between the species of bacterium found and the clinical
picture presented, to suggest from these findings the line of
therapy to be carried out, and to note carefully any details
in the cases, considered both individually and collectively,
that might tend to throw light upon the disputed points of
this question or to open up new lines of thought and investi-
gation.

The circumstances attending this investigation were ex-
tremely favorable. In the first place, an unusual opj^ortu-
nity was furnished for the study of the etiology of these

I The paper in full will appe.<ir in Volume. X, The Johns Hopkins
Hospital Reports.

infections as most of the acute cases were post-operative and
were most carefully studied before, during and after the
infection; in the second place, a careful cystoscopic exami-
nation was made in all the chronic and most of the acute
eases, so that no possible mistake could be made in the
diagnosis of the bladder infections; in the third place, the;
urine was obtained directly from the kidneys by ureteral
catheterization in all cases of supposed renal infection, and
from the urine so obtained the bacteriological, chemical and
microscopical investigations were made.

The cystoscopic examinations were made and the ureteral
catheterizations were done by Dr. Kelly, whom I wish to
thank sincerely for his unfailing kindness in this particular.
This work has been carried on during a space of two years
and comprises one hundred cases, besides numerous control
experiments.

The complete article will be subdivided into the following
sections: I. The method of obtaining the urine aseptically;

II. The chemical and microscopical examination of the urine;

III. The bacteriological study of the urine; IV. The cases of
acute cystitis; V. The cases of chronic cystitis; VI. The
cases of tuberculous cystitis which have been considered
separately for obvious reasons; VII. The cases with symp-
toms suggestive of cystitis but with no infection; VIII. The
cases of acute pyelitis and pyelonephritis; IX. The cases of
chronic pyelitis and pyelonephritis; X. The cases of tuber-
culous pyelitis and pyelonephritis; XI. A review of the
bacteriological, chemical and etiological findings in our
series; XII. A short resume of the work of other investi-

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

gators in this field; XIII. Polymorphism and other peculiari-
ties of the micro-organisms met with in our series, with a few
observations on the agglutination of the micro-organisms
found in cystitis, pyelitis and pyelonephritis by the serum of
the patient, and, XIV. A few therapeutic suggestions directly
dependent upon the results of the bacteriological and chemi-
cal studies. Under section IV will be found a note oa
bacteriuria, and under section IX some observations on the
relation between calculus and infection.

The number of cases in my series is exactly 100, subdivided
as follows: cases of acute cystitis, 26; cases of chronic
cystitis, 31 (alone 24, associated with pyelitis 7); eases of
tuberculous cystitis, 6 (alone 2, associated with renal tuber-
culosis 4); cases with S5rmptoms suggestive of cystitis but
with no infection, 17 (due to urinary hyperacidity !), due to
other causes 8) : cases of acute pyelitis and pyelonephritis, 3 ;
cases of chronic pyelitis and pyelonephritis, 13 (alone 4,
associated with cystitis 8); cases of tuberculous pyelitis and
pyelonephritis, 6 (alone 2, associated with cystitis 4).

It will be obviously impossible in an abstract as short as
this to give more than a very brief summary of the most
important findings in the various sections mentioned above.

I. The Method of Obtaining the Urine Aseptically
FROM Bladder and Kidney.

The following method was employed for obtaining the
urine aseptically: From the bladder; the vestibule of the
vagina and the mouth of the urethra having been carefully
cleansed with bichloride of mercury solution (1:1000) or
boracic acid solution (saturated) followed by sterile water,
the lips of the urethra are pulled apart by traction on the
labia and a sterilized glass catheter with a sterilized rubber
cuff, about 10 cm. long, on its distal end is introduced, the
operator only touching the rubber cufif at about its middle.
After the urine has flow'ed for a short time (so that if a few
micro-organisms from the urethra were introduced, they
would be washed out by the first-flowing portion of urine),
the rubber cuff is withdrawn by traction on its distal end and
10 to 20 ccm. of urine collected in a sterile tube, the cotton
]ilug of which is only removed during the reception of the
urine. In obtaining urine from the Mdney, the sterilized
rubber cuff is placed upon the distal end of the sterilized
ureteral catheter, which is introduced through a cystoscopy
into the ureter, great care being taken that it touches noth-
ing in its course until it is inserted into the ureteral orifice.
The bladder should be thoroughly washed out Just previous
to the procedure if there is the least possibility of a vesical
infection being present, while if an infection of the bladder
has been definitely determined either by urinary or cysto-
scopic examination, the ureteral orifice should be carefully
swabbed off with a solution of nitrate of silver and the
catheter inserted but a short way up the ureter (to prevent
any possibility of renal infection from the bladder); as in
the case before, the urine should be allowed to flow for a
short time before the withdrawal of the rubber cuff and the
reception of the urine in the sterile test-tube. Ordinarily
the urine flows drop by drop but. in case of pyoureter or

hydroureter, or pyonephrosis or hydronephrosis, the urine
first flows in a steady stream for a short time until the
dilated portion of the ureter or dilated renal pelvis is
emptied, when the catheter reaches that portion of the
ureteral or renal tract. The adequacy of these methods has
been shown by the negative results obtained in 53 control
experiments in the -ease of the bladder and 33 in the case
of the kidney.

II. The Chemical and Microscopical Study of the
Urine.

After having obtained the urine as described above, it is
essential that within a very short time (a few minutes if
possible) cultures should be made, as well as a careful chem-
ical and microscopical examination either of this specimen
or of a larger quantity obtained by catheter at the same
time. The reaction of the urine should be carefully testecT,
as by its acidity, neutrality or alkalinity it tells us in a broad
way something regarding the nature of the microbe causing
the infection. In cases with symptoms of cystitis but with
no infection, it is important to determine also the degree of
the acidity, which has been done in our cases by titration
with a 1-10 normal solution of sodium hydroxide, phenol-
phthalein being used as the indicator, for, as we shall see
later on, urinary hyperacidity may definitely cause symptoms
which may easily be mistaken for those of cystitis.

The specific gravity of the urine is of importance because
of the frequency of low specific gravities in cases of pyelo-
nephritis and also in cases of hysteria and the various
neuroses, and its determination is of especial interest when
both kidneys are catheterized, as well as the quantitative
determination of the t(7-ea-output from either kidney, so
that we may determine the secretory function of each — a
question of immense importance when nephrectomy is under
consideration.

The dctermiiuition of the quantity of albumin present is
of great importance because, combined with a careful cysto-
scopic examination and a determination of the grade of
pyuria and hematuria, it furnishes a valuable criterion for
the differentiation between renal and vesical infections.
which is of especial value in the hands of those to whom
ureteral catheterization is impossible. Of course the urine
must be examined shortly after its withdrawal, and consid-
erable experience must have been had in this mode of diag-
nosis; but, if these requisites have been fulfilled, one may
definitely conclude that if the grade of pyuria is decidedly
more marked than the grade of albuminuria, cystitis is prob-
ably present alone; while, if there is considerable dispropor-
tion in the other direction, it speaks for a renal infection,
alone or associated with a cystitis. If a person had a
chronic nephritis before the development and during the
course of the cystitis, the diagnosis would be rendered more
difficult, although the presence of casts in this last condition
woidd call our attention to this source of error. Obviously,
however, the only absolutely satisfactory method to be cm-
ployed is catheterization of the ureters combined with a
careful eystoscopic examination.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

The microscopical examination is of value because it tells
us of the absence or presence of vesical, ureteral and renal
epithelial cells; it calls our attention to the crenation or
lack of crenation of the red and white blood-cells (the
former of which conditions speaks for a renal hematuria
or pyuria if the grade of these conditions is low — if the
pyuria or hematuria is of high grade this method of differen-
tiation is of very little value); and it tells us of the mor-
phology, number and motility of the micro-organisms giving
rise to the infection. By counting the red and white blood-
cells in a definite quantity of mixed urine (1 cmm.) with the
Thoma hematocytometer we can definitely determine the
success or failure of the mode of treatment employed.

III. The Bacteriological Study of the Ueine.

The methods of making the cultures and identifying the
bacteria found are those usually in vogue, two or three loops
of urine or of diluted urine being first plated on agar-agar
from which transplantations can be made on the various
media. The bacilli should also be counted on the plates so
that, by studying the cultures taken from the urine from
time to time, the success or failure of the method of treat-
ment employed may be definitely determined.

In all cases, except perhaps acute post-operative cases, the
tubercle hacilli should be carefully searched for in the sedi-
ment, while if there is pyuria or hematuria in an acid urine
but with no growth on the ordinary media, intraperitoneal
injections into guinea-pigs should also be employed.

In any specimen where the history of the case or the
microscopical examination of the sediment makes us suspect
the presence of the gonococcus, this micro-organism should
be sought for by the use of special media and of special
staining reactions.

INFECTIOXS of THE BLADDER.

In our series of cases we have divided the cases of cystitis
into acute, chronic and tuberculous, and then subdivided
these groups along bacteriological lines. We have consid-
ered those cases as acute in which the infection has been
present but a short time, where there is no real contraction
of the bladder and where there are no distinct areas of
ulceration, while in the chronic cases the duration has been
longer, there is practically always more or less ulceration,
and the bladder is distinctly and usually markedly con-
tracted.

IV. Cases of Acute Cystitis.

These cases are of especial interest because of the fact
that, as all but two of the 26 cases studied were post-opera-
tive infections, in which the urine had been carefully exam-
ined immediately preceding the operation, they furnish us
with absolute criteria as to the micro-organisms bringing
about the infection and the other etiological factors involved.

In all these cases the micro-organism causing the infection
was present in pure culture and generally in large number;
in practically all of the cases two and in the rarer ones three
or more cultures were made, and in the post-operative cases

a culture was always taken after the disappearance of symp-
toms; in all these 24 cases the infection entirely disappeared
under treatment. The urine in all these acute infections
contained varying numbers of pus-cells, red blood-cells and
vesical epithelial cells.

The bacteria found in these 26 cases were: B. coli com-
munis 15 times, or 57.7 per cent; staphylococcus pyogenes
albus 5 times, or 19.2 per cent; staphylococcus pyogenes
aureus twice, or 7.7 per cent, and B. pyocyaneus, B. typhosus
and B. proteus vulgaris (of Hauser) once each, or 3.8 per
cent, while in one case, microscopically, a colon bacillus was
found, although the cultures were not completed.

In all the cases except one — that due to B. proteus vulgaris
(where the urine was ammoniacal) —the iirine was acid,
although the degree of acidity varied markedly with the
variety of micro-organism, being usually increased in the
case of the colon bacillus and typhoid bacillus infections, and
diminished in the case of the staphylococcus infections,
especially in the case of staph3doeoccus pyogenes aureus,
where the urine was sometimes neutral in reaction. Especi-
ally striking is the prevalence of the colon bacillus and the
absolute proof that this micro-organism can by itself give
rise to vesical infections as furnished by these studies, while
the infections due to the pyocyaneus and typhoid bacilli are
of great interest, because of their extreme rarity. These
last two cases are reported in full elsewhere {Marijland Medi-
cal Journal, 1900, May; Medical Eecord, 1900, March 10).

The time of the development of the symptoms varied between
the 3d and the 20th days after the operation, being shorter
in the cases of B. proteus, St. pyogenes aureus and some of
the infections with B. coli communis. Apparently the more
virulent the micro-organism and the more severe the symp-
toms, the earlier after the operation the infection manifested
itself.

The mode of entrance of the bacteria into the bladder in the
majority of these cases was undoubtedly from the urethra
by catheterization, although this procedure was performed
with extreme care, which is not at all remarkable when we
consider Melchior's, Savor's, Gawrowsky's, Bouchard and
Charrin's researches upon the bacterial flora of the normal
urethra and vulva, colon bacilli and various staphylococci
being frequently found.

In some cases, however, infection seemed to have taken
place definitely from the rectum or from some focus of
infection either by means of the blood or lymph currents
or by direct transmission.

We were, however, at once struck in considering our cases
of acute cystitis by the fact that other accessory etiological
factors seemed to be absolutely necessary for the production
of the infection in the great majority of these cases, which,
so to speak, prepared the bladder for the reception of these
germs and rendered it susceptible to their usually low patho-
genic power.

The most important of these factors, as evidenced by our
series, were anemia and malnutrition, constant pressure on
the bladder by other organs or by new growths, sagging of
the bladder due to relaxation of the perineum, trauma to

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

the bladder either duo to the operation or to the catheteriza-
tion (these are nndoubtedly the most important of these
accessory factors, as evidenced by the fact that in almost all
the cases of post-operative cystitis the nature of the opera-
tion was such that considerable trauma of the bladder was
inevitable), the trauma and congestion of the bladder inci-
dental to child-birth, catheterization with poor technic^ue.
and a contiguous focus of infection (a large appendicular
abscess in one of our eases). In the case of the urea-splitting
micro-organisms (B. proteus vulgaris), the presence of the
bacteria plus the irritation of the amnioniacal urine seems
sufficient to bring about a cystitis.

No examples of true vesical lackriuria were met with in
our cases, but in a few there was seen a condition nearly
approaching this, i. e. enormous numbers of bacteria but
very few pus-cells in the urine.

V. Cases of Chronic Cystitis (non-tuberculous).

The cases varied markedly in duration and in severity; in
some cases the symptoms were comparatively slight, in other
cases so severe as to render life practically unbearable.
Thirty-one cases in all were studied, in 34 of which cystitis
alone was present while in 7 a pyelitis was associated with the
cystitis. In 3 of these latter cases the pyelitis had preceded
the C3'stitis and in 4 the reverse had taken place; in all the
first 3 the vesical symptoms were very slight. In this series
of 31 cases B. coli communis was met with 16 times, or 55.2
per cent (15 times in pure culture, once in association with
the tubercle bacillus); St. pyogenes aureus 3 times, or 10.3
per cent; St. pyogenes albns twice, or 6.9 per cent; a slowly
liquefying (gelatin) urea-decomposing white staphylococcus
4 times, or 13.8 per cent, and B. proteus vulgaris once, or
3.4 per cent. With the exception of the one case mentioned
(B. coli and B. tuberculosi), the micro-organisms were always
present in pure culture. Of the 31 cases, the urine was acid
in 26 (occasionally neutral or exceptionally slightly alkaline
in some of the staphylococcus infections), alkaline or am-
nioniacal in 5 (B. proteus vulgaris, slowly-liquefying urea-
decomposing white staphylococcus), although in some of
these latter cases, when the bladder infection is very slight
and the renal infection marked, the urine may be neutral oi'
even acid.

The common modes of infection seemed to have been from
the vulva or urethra usually by catheterization, from the
rectum, from the kidney, from poor technique in examining
or treating the bladder. The other factors in the etiology of
the condition were practically the same as in our series of
cases of acute cystitis; a new accessory etiological factor is
to be found in this series in operations upon the urethra.

VI. Tuberculous Cystitis.

Six cases of tuberculous cystitis were met with in oui-
series. In one case and possibly in another, the cystitis
occurred alone; in the other cases it was associated with a
tuberculous pyelitis or pyelonephritis. Five of the cases
were chronic; one was comparatively acute. The constitu-
tional symptoms and the vesical lesions were marked in all

these cases but one. In all, tubercle bacilli were found,
usually in small numbers, occasionally in comparatively large
numbers. They were present in pure culture in all but one
case, where the colon bacillus was also present (secondary
infection after a suprapubic cystotomy). The urine was
alwaj's markedly acid and contained usually a large niimber of
pus and red blood-cells, the latter being comparatively more
frequent than in the other cases of chronic cj'stitis. The
mode of entrance of the bacilli was difficult to determine; the
bladder seemed to be affected first, probably by metastasis
from some tuberculous focus elsewhere in the body. Other
etiological factors were difficult to determine; only one case
gave a family history of tuberculosis and only one showed a
pulmonary lesion; in some cases weakness, anemia and mal-
nutrition seemed to have rendered the bladder susceptible
to the infection. In some cases the onset was gradual and
insidious, in other cases the symptoms of onset were those
of a typical acute cystitis.

VII. Cases avitii Symptoms of Cystitis bttt with no
Infection.

Besides the increased frequency of urination, burning
sensation, etc., seen after the use of various drugs and in
certain neurotic conditions, we have met with two classes of
eases with symptoms of cystitis but with no infection. The
first class is of especial interest, the symptoms being due to
urinarij hyperacidity, which was determined by titrating 10
cem. of freshly drawn urine with one-tenth normal sodium
hydroxide solution, phenol-phthalein being used as the indi-
cator. Nine such cases were met with and the acidity of the
urine varied from twice to five times the normal. The urine
always contained a ievf, and in the more severe cases a mod-
erate number of pus and red blood-cells, while cystoscopic
examination usually revealed a markedly ingested trigonum.
The condition seems to be one of the manifestations of a
general neurosis which requires general as well as local treat-
ment, the latter of which consists mainly in the neutraliza-
tion of the intense acidity of the urine by the administration
of alkalis by mouth. Cultures of the urine were always
negative and the condition, so far as I knou-, lias not
definitely been described previously. The condition is of
especial importance because, if misinterpreted, local appli-
cations, irrigations, etc., are frequently inaugurated which,
in the hands of all but the most' careful and skillful, fre-
quently lead to vesical infections.

Eight cases with symptoms of cystitis hut with no infec-
tion are reported due to other causes; such causes are relaxa-
tion of the vaginal outlet, especially if marked anteriorly,
retroflexed uterus, pelvic inflammatory disease with vesical
adhesions, large pelvic neoplasms pressing upon the bladder,
mucous polypi protruding from the vagina, and varicosity of
the vesical veins. If the pathological condition is corrected
by operation, the vesical symptoms shortly disappear.

pyelitis and pyelonephritis.

These studies are unique in that the urine from which they
have been made was obtained directly from the kidney by

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

ureteral catheterization. Both kidneys were usually cathe-
terized, so that the two sides could be compared— a most
important point in determining upon the advisability or non-
advisability of nephrectomy.

VIII. Acute Pyelitis and Pyelonepheitis.

Only two cases were met with, in both of which the renal
infection was secondarj' to the bladder infection. One was
due to B. coli communis and the urine was acid; the other
was due to B. proteus vulgaris, and the urine was alkaline.
In either case the other kidney was perfectly normal. It
was interesting to note that in one of these cases the affected
kidney was the one suspended at the operation.

IX. Chronic Pyelitis and Pyelonepheitis

(non-tuberculous) .

Twelve eases of this condition were studied, in 4 of which
the pyelitis was present alone, in 8 associated with cystitis.
Catheterization of both kidneys showed that the infection
was unilateral in all but one case. The symptoms were very
variable, being sometimes almost nil, sometimes very severe.
The urine from the infected kidney was usually pale, of less
specific gravity, increased in amount, low in urea percentage
and contained a greater or less number of pus-cells, some
red blood-cells and ureteral or renal epithelial cells. The
bacteria found in these 12 cases were : B. coli communis G
times, or 50 per cent; B. proteus vulgaris 3 times, or 25 per
cent;- the slowly-liquefying, urea-decomposing white staphy-
lococcus twice, or 16.7 per cent, while in one case there was
no growth, the infection evidently having died out. The
urine was acid in the colon bacillus cases, alkaline in the
cases due to the other micro-organisms. As to the mode of
infection, in 5 the bladder was infected first and the kidney
secondaril}', evidently by an ascending ureteral infection,
while in 5 and probably in one other the kidney was infected
first; that is, the infection was probably carried directly to
the kidney by means of the blood or lymph currents ; in one
case the infection was an ascending ureteral infection, there
being a uretero-vaginal fistula.

An interesting point regarding the relation hettveea infec-
tion and calculus formation was to be made out from a study
of these cases. In all 5 cases of chronic pyelitis, where the
urine was alkaline due to a urea-decomposing micro-organ-
ism, a renal calculus composed of phosphates and carbonates
of calcium and magnesium was found, while from the centre
of one of the calculi a pure culture of the micro-organism
causing the pyelitis was obtained.

X. The Cases of Tuberculous Pyelitis and
Pyelonephritis.

Six cases of this nature were met with, in 2 of which
the renal infection occurred alone, while in the other 4 a
vesical infection was associated with it. One of the cases
was an acute infection, while 5 were chronic. All eases
were pure infections and in all 6 the tubercle bacilli were
found in the urine. The urine was always acid, contained
considerable albumin, many pus-cells, more red blood-cells

than seen in the other forms of pyelitis, and renal and
ureteral epithelial cells. None of the 6 cases gave a tuber-
culous family history and only one showed a tuberculous
lesion outside the urinary tract. In 4 of the cases the
kidney seemed to have become infected from the bladder by
an ascending ureteral infection.

In the complete article, section XI is devoted to a general
consideration of the results obtained, and section XII to a
discussion of the bacteriological results obtained by other
observers.

Section XIII treats (1) of the polymorphism of various
bacteria, especially' as regards variation in cultural pecu-
liarities, motility and virulence of the colon bacilli and the
chromogenic properties of the staphylococci, and (2) of the
agglutination of the bacteria by the patient's serum in
cystitis and pyelitis, a positive reaction being obtained in
2 of the 3 cases tested.

Section XIV deals with a few therapeutic snggestions
directly dependent upon the bacteriological findings, the
question of treatment not being further discussed in this
article, as it obviously belongs more to the surgeon than to
the bacteriologist. To render the urine a poorer medium
for the growth of bacteria and to help to wash out thu
bacteria, pus-cells, etc., present, large quantities of water
should be administered, preferably by mouth, but if this is
not feasible, by rectal enemata or by subcutaneous injections.
The administration of substances which render the urine
somewhat antiseptic, as urotropin, cystogen, salol, etc., is
advisable, especially in the acute cases. Also in cases asso-
ciated with an alkaline urine, acids such as boracic, benzoic
or camphoric acids should be given by mouth in sufficient
quantity to render the urine acid, while in the acid infections
alkalis should be given until the urine is alkaline, as it
would seem probable that by these means we diminish the
growth of the respective micro-organisms by furnishing a
less favorable medium. The same condition of inhibition
of growth would probably be brought about in any case by
the administration of a great excess of either acid or alkali.
It is essential that the resisting power of the patient be
increased as far as possible by a careful attention to all
questions of personal hygiene, the insistence upon plenty of
fresh air, sunshine and good food, the removal of depressing
or very exciting influences, the attention to any disorders of
the blood, the circulatory and respiratory organs or the
organs of digestion and elimination if such conditions arc
present. Of course, in many cases other measures besides
the ones just mentioned have to be employed, such as topi-
cal treatment, irrigations, instillations (nitrate of silver has
proven of most value to us in these connections), operative
treatment of various kinds, etc., and the above are but the
suggestions regarding the general medical treatment of cases
of cystitis, pyelitis and pyelonephritis derived directly from
the bacteriological study of the cases.

Discussion.

Dr. Young.— I have enjoyed this paper and I think Dr.
Brown is to be congratulated for his excellent work. My

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

interest in this subject has extended over several years, as
I luive been working, particularly on male subjects, during
that tijiie along the same line. In looking over the results
obtained I was struck by the gj-eat dissimilarity of the
i)i-ganisnis we have found. ]\[y work includes, I thiuk, three
or four times as many organisms as have been found in the
cases studied among the females. For instance, among
others I found all forms of the proteus, the streptococcus,
tlic stapliylococcu.s albus and the aureus, the bacillus lactis
aerogenes, and, several times, the gonococcus.

Another discrepancy between our results is that the colon
bacillus, which occurred in tlie great majority of cases in
the female, was not so often found in the male. The staphy-
lococcus pyogenes albus in my cases was found to be a mucli
more common cause in the male of acute or chronic cystitis
and nephritis.

One particularly interesting point in the jiaper is in regard
to the effect of these bacteria upon the urine, as Dr. Brown
has mentioned. For instance, in my cases with a pure colon
bacillus infection there was always an acid reaction, while
with the ijroteus there was a marked alkaline or ammoniacal
reaction. If both were present in the same case there was
usually only a slight alkalinity, the acid-forming colon bacil-
lus apparently neutralizing more or less completely the alka-
jinizing effect of the proteus group. In one case I was
al)Ie to prognosticate the presence of these two organism^
simply upon the finding of a very slightly alkaline urine with
the presence of large numbers of bacilli — enough to have
made it strongly acid if colon alone were jiresent, and very
alkaline if proteus were the sole organism.

We have encountered a number of sta])hylococci that
could not exactly be classified; in fact, there were all grades
of staphylococci in the cultures I have examined, some re-
quiring 15 days to liquefy gelatin and some that did not
li(pu'fy it at all, and I suspect that Dr. Brown's staphy-
lococci belong to the group that Melchior has called the
diplococcus urea; non-liquefaciens.

As to the amount of albunun in making a diagnosis of
]iyelitis from cystitis, I think from practical experience it is
often pretty difficidt to determine. Finger, discussing the
question of infection of the pelvis of the kidney after gonor-
rhoea, says that if the albumin has reached 1.5 per cent you
can generally safely consider that the pelvis of the kidne\
is involved, but we have noticed in examinations of the urine
in cases of cystitis the amount of albumin varied very
greatlv, sometimes being present in considerable amount,
sometimes entirely absent, with similar amounts of pu<
])resent.

Dr. Brown's case of typhoid infection of tlie bladder is
certainly a very interesting one. In the first place, tlir
organism was introduced from without; and, secondly, it is
the only case I believe in which a careful cystoscopic studx
has been made in an acute cystitis due to the bacilhi-
typhosus. The sjTiiptoms in his case were very severe and
differ in that respect from the usual cystitides following
tyj^hoid fever. In a great majority of cases in which the

bacillus appears in urine after typhoid fever there is no irri-
tation at all. It seems to be the fact that infection of the
bladder by the typhoid bacillus is a very mild one in most
cases, but I have recently had a case of severe chronic
cystitis, with marked ulceration of the mucosa, in which the
bacillus typhosus was the sole infecting bacterium, and that
seven years after the attack of typhoid fever.

In all the cases infected with the proteus I have had the
urine has been strongly alkaline, but we have recently had
one case in the hospital that had an acid reaction, and a
study of the organism by Dr. Sabin showed it to be the
proteus Zenkeri, which is not as pronounced in its effect
upon media and is not an alkalinizer; if inoculated into
sterile urine it renders it acid. This is interesting in that
bacteriologists, I believe, consider all the proteus organisms
to belong to one group and to be interchangeable.

Gonococcus infections of the bladder were not present in
Dr. Brown's cases, and I believe they are much more common
in the male, owing to the greater severity of the urethral
inflammation in the latter. Thus I have found this organ-
ism six times in the bladder, in three acute and three chronic
cases of cystitis. The only other cases jn the literature,
however, where cultivations of the gonococcus were obtained,
were in the female, the difficulty of obtaining cultures
from the bladder of the male in acute gonorrhreal infections
being the probable cause. This was overcome in my eases
by aspiration of the bladder above the symphysis.

The demonstration of the ease with which the- bladder
may bi' aspirated for cultures will probably soon increase
the present limited number of observations on the ability of
the gonococcus to invade the bladder.

Dii. Welch. — There are only one or two points which I
shall undertake to discuss in Dr. Brown's very interesting
and important paper. I am impressed by the fact that both
Dr. Brown and Dr. Young find that bacteria which have
ordinarilyVery limited pathogenic activity and do little harm
elsewhei'e in the body are so often concerned in cystitis and
pyelitis. This is the more remarkable as it has been demon-
strated I hat the healthy bladder is capable of disposing of
large nundiers of much more virulent kinds of bacteria. The
The slowly-liquefying and the non-liquefying white staphy-
lococci we are accustomed to regard as among the least
pathogenic pyogenic cocci, and still these are apjiarently
often present in the urine in cystitis and are interpreted
as the exciting factors in the causation. This should in
my opinion lead us to attach much importance to various
accessory causes which render the urinary passages incapable
of resisting even these mildly pathogenic bacteria, and it
would be a one-sided view which failed to take into consid-
eration in the etiology of cystitis and pyelitis the non-
bacterial factors.

The ((uestion has been raised as to the identity of the
non-lii|uefying white staphylococcus. I should like to in-
quire whether the coccus in question may not be Staphy-
lococcus cereus albus. There is every gradation among the
pyogenic staphylococci as regards such properties as rapidity

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

and intensity and tint of color-production, liquefaction of
gelatin, coagiilation of milk and virulence when tested on
animals, so that there is much in favor of the view that the}'
are varieties of a common species. We have been in the
habit of designating as Staphylococcus epidermidis albus the
slowly liquefying and slowly coagulating white staphy-
lococcus, which, moreover, is of limited virulence and, as
has been abundantly demonstrated, is a regular inhabitant
of the human epidermis. I should infer from Dr. Brown's
description that this Staphylococcus epidermidis albus has
been often encountered by him in cases of cystitis.

De. Hunner. — I have been struck with the apparent non-
relationship between the degree of bladder disease and the
infecting organism which under other conditions is often
very virulent. Especially is this true in my experience with
the streptococcus.

We had a ease in Dr. Kelly's service last fall who was the
wife of a physician and had been under careful observation.
Eight weeks before adniission her first sign or symptom of
disease appeared in the form of a marked hematuria, the
urine being of a claret color and occasionally containing
small bright red clots. After three weeks she became
anemic, had occasional pains in the right kidney region, and
experienced some headache, giddiness, and nausea. There
had been no elevation of temperature until two weeks before
admission, when she was suddenly taken with a severe shak-
ing chill which lasted one and one-half hours and was fol-
lowed by a rise of temperature to 104.3° F., violent headache,
pains in the legs, retching, vomiting, and great restlessness.
The temperature gradually subsided but had reached 100°
every afternoon since. The urine was found to contain great
numbers of streptococci in pure culture, and a catheterized
specimen from the right kidney showed infection by the
same organism. Nephrectomy was done and a small stone
was found in one calyx with multiple foci of necrosis scat-

tered throughout the kidney. The bladder mucosa seemed
entirely healthy.

A patient was admitted this spring who had suffered with
symptoms of stone in one kidney for the past two years, and
in both kidneys for three months past. Streptococci were
obtained in pure culture from the bladder and from either
kidney, but the bladder mucosa showed no lesion. Wax-
tipped bougies were scratched by stone in either kidney.

A case came in a day or two ago and from her history stone
in the right kidney was suspected. On catheterization of
the bladder macroscopically, clear urine was obtained. Cysto-
scopy revealed a healthy-looking bladder. I catheterized the
right kidney with a wax-tipped bougie and obtained scratch-
marks from stone. On examination of my plates to-day I
was surprised to find a pure growth of streptococcus both
from the bladder and the right kidney.

Dr. Brown. — I would like to say that one of- the probable
reasons why the bacterial flora in my cases is not so large as
in Dr. Young's experience is that my cases were taken
entirely from private patients where the chances of infection
are decidedly less.

In regard to the disputed staphylococcus, I thought, of
course, that it possibly was identical with the diplococcus of
Melchior but could not convince myself of it, as it certainly
showed no especial tendency to assume the diplococcal
arrangement.

As I have stated before, the infections were almost always
confined to those cases in which the resistance was very low,
or the traumatism of the bladder was marked.

I have not attempted to carefully differentiate the various
white staphylococci found in these cases, for it seems almost
impossible to satisfactorily separate these micro-organisms
into especial groups, as all gradations in cultural peculiarities
were met with. As Dr. Welch has stated, some of them
certainly could be best considered as Staphylococci epider-
midis albi.

THE INTRINSIC BLOODVESSELS OF THE KIDNEY AND THEIR SIGNIFICANCE

IN NEPHROTOMY.

By Max Bbodel.

[PRELIMINARY COMMUNICATION.!]

In view of the enormous number of investigations of the
different structures of the kidney recorded in the literature

1 Since this article was sent to press, I learned that Dr. William
Keiller, of Galveston, Texas, lias been followiDg a similar line of
research. His findings were embodied in a report to the Te.^cas State
Med. Soc, in whose Transactions for 1900 they appear. I have just
received through the kindness of Dr. Keiller some of his specimens
which substantiate many of the points brought forth in this paper,
although the methods he employed differed essentially from miue.
This being merely a preliminary communication precludes the possi-
bility of discussing in detail Dr. Keiller's excellent work.

it seems strange that only scanty information exists on the
actual course of the larger blood-vessels and their relation to
the pelvis of the kidney. The normal and abnornuil arrange-
ment of the vessels at the hilum are well known and the
microscopical pictures of the vessels in the cortex and
pyramids are likewise thoroughly familiar to every student.
But as to the actual form of the pelvis and the course and
distribution of the larger vessels around its walls very vague
ideas still prevail. It is evident that exact knowledge of
the anatomy of this region would prove of the utmost im-

jANtlARY, 1901.]

JOHNS:: HOPKINS HOSPITAL BULLETIN.

portanco to the surgeon in enabling him to open the pelvis
of the kidney withont running the risk of cutting largo
branches of the renal artery.

In order to study this region I made a large number (40)
of celloidin injections of human kidneys. The injected
specimens were then digested ' and the casts thus obtained,
examined. Nearly thirty additional injected kidncj's were
not digested, but were cut into sections in various planes
in order to control the results obtained by the method of
digestion. Some of these sections were rendered translucent
by the usual methods.

I made separate injections of the arteries, of the venous
system and of the pelvis, combinations of any two out of
three and finally triple injections. The great majority were
of the last class. At first I confined my injections to kidneys
which seemed normal so far as regarded form and size ; later,
after I had, in this way, determined the law according to
which the vessels were grouped, I concentrated my attention
upon abnormally shaped kidneys. The present paper will
contain a short abstract of the main results of these studies.
I shall confine myself to the description of the normal form
and mention briefly only a few variations. A more elaborate
communication will appear later.

The Pelvis of the Kidney. — From a surgical standpoint all
forms of pelves may be classified under two main groups.

(1) True pelves with major and minor calices.

(2) Divided pelves, where there is no free communication
possible between all of the calices inside of the kidney.

(1) True Pelves. — Fig. 1 shows the ideal form of a true
pelvis. There are eight calices; the uppermost (1) and
lowest (8) of which may have double papillie. The remain-
ing six calices stand upon the pelvis in a double row; an
anterior, irregularly arranged (2, 4, 6) and a posterior, more
regular, row (3, 5, 7).

The horizontal axis of the pelvis (Fig. 1 D, a, a') runs from
the posterior surface of the kidney obliquely through the
organ to the outer third of its anterior surface and the two
rows of calices leave this axis at almost equal angles. Tho
posterior calices, therefore, point to a line just a little pos-
terior to the lateral convex border of the kidney (&), whib;
the anterior calices are directed straight forward into the
convex anterior region of the organ (c). This form of the
pelvis is, next to the distended pelvis, the most favorable for
a surgical incision.

p i! I employed Schieferdecker's corrosion-method, sliglitly modified by

I Mister .and Mall. The procedure was as follows : The vessels and pelvis
of the kidney were thoroughly washed out and then dehydrated with
alcohol and ether. The arteries, veins and pelvis were then injected
with cinnabar, Prussian blue and arsenic preparations of an alcohol and
ether solution of celloidin, respectively. The kidney was then placed
in a digesting fluid consisting of varying amounts of l-.'AOOO pepsin
(Sharp & Dohme) dissolved in 0.3 per cent to 0..5 per cent of HCl. The
process of digestion was completed in from three or four days to two
weeks. When the substantia propria and the connective tissue of the
kidney were completely dissolved, they were washed out with a gentle
stream of water, leaving only the casts of the injected vessels and
pelvis. The casts were preserved in glycerin to which a few drops of
carbolic acid were added.

The great majority of pelves have well defined major
calices, with a very narrow lumen, and owing to this condi-
tion it is often impossible to gain access to the minor calices
and remote pockets through a surgical incision into the
pelvis at the site of the hilum. Furthermore, this incision
must be short, as there is a constant branch of the renal
artery running downward over the posterior surface of the
pelvis at the hilum.

The varieties of the ideal form are very nuanerous and
will be described in detail in the fuller communication above
referred to. All kidneys with a true pelvis have a smooth
surface or moderate degree of lobulation, regular outline
and, as a rule, a normal blood-supply.

(3) Divided Pelves. — Fig. 2 shows the typical form of a
divided pelvis. Comparing it with Fig. 1 one finds that
between calices 2, 3 and 4, 5 there is a zone of cortical
substance (a), which extends to the hilum. It divides the
upper part of the pelvis from the lower, and in the majority
of cases the lower portion receives the greater number of
calices. Although the number of calices in divided pelves
may be eight, they are generally more numerous. In other
respects the topography of these pelves is similar to that oi
the true pelves. A kidney with a divided pelvis, as a rule,
preserves its fcetal lobulations and has an abnormal arterial
circulation; the division between the individual sections of
the pelvis is generally marked on the surface by an especially
deep groove, thus causing the appearance as though there
were two separate kidneys, one on top of the other. Fre-
quently they are indeed separate organs as far as their secre-
tory function and their arterial circulation are concerned.
The veins, however, collect, as a rule, in one single trunk.
These conditions are readily understood by one who is
familiar with the different stages of the development of the
kidney, with its origin, its ascent from the pelvis to the
lumbar region and finally the wandering in of the vessels.

The Benal Artery. — The renal artery divides at the hilum,
as a rule, into four to five branches, the distribution of which,
in relation to the pelvis, is such that three-fourths of the
blood-supply is carried anteriorly, while one-fourth runs
posteriorly. The relative size of tlie two systems may occa-
sionally be f : ^, § : i, but rarely ^ : i. The arteries are
end-arteries in the strictest sense of the word and the
branches of the anterior division never cross over to the
posterior side, or vice versa. They do not anastomose with
each other.' The plane of division between the two arterial
trees is indicated by the axes of the posterior row of calices
(see Fig. 1 D 6 and Fig. 3 B arrow).

Fig. 3 B demonstrates this in a schematic way. The sec-

3 To Hyrtl apparently is due the credit of having first mentioned the
"uatiirliche Theilbarkeit der Siere," by which he means that in a
corrosive specimen the two arterial systems are completely separated
by the pelvis. He also affirms that this arrangement of the renal arteries
is found "without exception in all mammalia from tlie whale to man."
[Hyrtl, Topographische Anatomie. Wieu, 1883. Bd. I, pg. 834.]
Hyrtl's statement has unfortunately been overlooked and up to this date
the text-books on anatomy and surgery make no mention of this anato-
mical fact, so important to the surgeon.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. lis.

tion is imagined as passing transversely through the midflle
of the iiidney, as in the lower diagram in Fig. 1. Tiio artery
(a) sends a large branch (a') anteriorly and a small branch
(a") posteriorly. Both branches are seen running close to
the pelvis and the calices up to the region of the papillse,
whence they send off fan-like branches (b) around the pyra-
mids. The anterior branch (»') supplies the wliole of the
anterior pyramid (P) and the anterior portion of the pos-
terior pyramid (P'), while the posterior branch (a") supplies
only the remaining portion of the posterior pyramid (P').
The arrow indicates the division between the two vascular
trees, c represents a section of the long lateral column of
cortical substance, which is situated between the anterior
and posterior rows of pyramids P and P'.

The greater part of the arterial circulation of the kidney
follows this system. The entire region from calices 2 to 7
.has this arrangement. Around the uppermost (1) and lowest
(8) calyx, however, the arteries have a somewhat different
arrangement (Fig. 4). They are derived from the anterior
group of vessels and run either as a single trunk, having a
diameter of 2-3 mm., to the base of the major calyx, or
divide before they reach the calyx into three branches, I, II,
III. Branch I and branch III run courses similar to those
of branches a' and a" in Fig. 3 B, i. e. anteriorly and poste-
riorly to the calyx. It is obvious that their arrangement must-
prolong the arterial division, existing in the central portion
of the kidney, upward and downward. Branch II may be
short, as in Fig. 3 A (upper pole), and vessels coming from
branches I and III partially may take its place. Or it may
be of considerable length, as in Fig. 5, where it makes a long
sweep around the inner border of the pole. Branch II is the
one that generally plays the role of the supernumerary
artery; it may arise from the renal artery near its aortic
origin (Fig. 5 a and 6) or even from the aorta (Fig. 5 c); in
the latter case it must be considered a supernumerary artery.

Although separate arteries are found in kidneys with
smooth surfaces, they are much more frequently met with in
those that have preserved their foetal lobulation. This ab-
normal arrangement of the arteries is, perhapts, the cause of
the persistence of the lobulated form. When he meets with
a kidney having a distinctly lobulated form, the operator
may expect to find a long hilum with separate arteries and
an abnormal renal pelvis.

The further course of the arteries, the irregularities that
may occur and to what extent they affect the above described
schema, will be dealt with in a fuller communication.

The Renal Vein. — Concerning the veins, I shall here record
only a few notes dealing with their more important char-
acteristics.

While there is a complete arterial division in the plane
connecting the posterior calices and terminating in the lat-
eral half of the upper and lower calices, the veins follow
quite a different arrangement. Around the bases of the
pyramids they anastomose and form the familiar venous
arches. They unite in large branches that run between the
sides of the pyramids and the columns of Bertini to the
necks of the calices, where they lie between the pyramid and

the arterial branches. The thickness of these collecting
veins accounts for the peculiar lobulated appearance of the
base and sides of the pyramids (Fig. (5 B). Around the necks
of the calices, both anteriorly and posteriorly, these veins
form a second system of anastomoses (Fig. G B &) much
shorter and thicker than that at the base of the pyramids {a).
This appears as a number of thick loops or rings which fit
like a collar around the necks of the calices. Nearly all the
collected blood of the posterior region is carried anteriorly
through these short thick stems, to join that of the anterior
portion at the point indicated by c.

In comparing Figs. 3 and 6 one finds that an incision
through the posterior row of calices would avoid all the
arteries but would sever six of these collecting veins. As
there remain, however, sufficient anastomoses at the upper
and lower pole of the kidney, no serious consequence should
follow an injury to these veins. The large veins at the
hilum are generally described as being in front of the artery.
This is, however, only the ease in the neighborhood of the
vena cava, while at the hilum and tliroughout the entire
kidney the veins are usually situated between the arteries
and the pelvis.

The Surface of the Kidnc;/ and its Eelatinn to the Under-
lying Structures. — If one is thoroughly familiar with the
kidney's surface it is a comparatively easy matter to deter-
mine the arrangement of the underlying structures; one can
map out fairly accurately the position of the pyramids, of the
columns of Bertini and of the calices; and as a consequence
the position of the plane of arterial division can also be
determined. Let us consider briefly the principal landmarks.

The anterior surface (Fig. 7 B) of a normally shaped
kidney is convex and has its greatest liromiuejice at tlie lower
portion at the point indicated by a. The posterior surface
(A) is somewhat flattened. A lateral view of the organ (C)
shows this very clearly; there is also rendered visible a
depression(?) h'), which indicates the position of the lateral
column above referred to, or the line of division between the
anterior and posterior rows of pyramids. This depression,
however, by no means indicates the division between the
arterial systems, as below it is situated the greatest number
of large vessels contained in the kidney. This line (& h') is
therefore a most important landmark and in every neph-
rotomy should be thoroughly mapped out. The other depres-
sions on the surface indicate the positions of the margin-
of the individual pyramids or subdivisions of such.

Fig. 8 shows the same kidney as Fig. 7, with its pyramids
and calices schematically drawn. The posterior pyramids
(A 3, 5, 7) are long and slender, while the anterior ones
(B 2, 4, 6) are more rounded at their base, thicker and do
not extend so far laterally as the posterior pyramids. Con-
sequently, the line of division (D 6 and b') between the pyra-
mids leans more towards the anterior surface of the kidney,
so that the anterior surface of the organ bulges, while the
posterior is flat.

Between the pyramids are the columns of Bertini which
carry the larger vessels. Fig. 8 C shows that these columns
join in a longitudinal column (b b'), in which all of the largest

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE III.

-o

1=1

if s

c 2 '*^

_jy.n/wiv^'

-3 «J b/; .-

S :3 ■= S 5
1-J vi 3J <aJ —

ft. -p ,a 15 M o

3 s

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE IV.

Fig. 2. — Left kidney with typical form of a divided iielvis. The two divisions of tlie pelvis are separated by an area of
cortical substance {a] extendini: almost to the hilum. As a riih' the upper division is narrow and has fewer calices than the
lower. The division between the two branches of the i)elvis is senerally marked on the surface of the kidney by a deep
depression.

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE V.

Kui. ;;.— TliL- rc-inil iirtLTV :ni(l tlit- ilisti ibiitioii i>f its tiiMiiclies
ill relation to tlic pelvis.

.\. Anterior view of a lelt kidney. Tliere Mre I'l main
branebes seen euterius; the Kidney siibstanee. Only one of
tliese (tbe third) passes posterior to the pelvis at the hilnm,
also small arteries coiuiug from the uii|ier ami lower main
branebes are seen to pass posterior to tlie iippi-r and lower
caliees. All the rest of tbe arteries pass anterior to tbe pelvis
and its caliees. Tbe small branebes to tbe eortex of tbe
anterior portion of tbe kidney have not been drawn in order
that the large branebes and tbe pelvis might appear more
distinetlv.

y> o s t

B. Transverse section through the middle of the same
kidney seen from above. The anterior branch of the artery
supplies about ?.i of the kidney substance while the posterior
1. ranch supplies only '4. Tbe dotted line and arrow indicate
tlie plane of arterial division.

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE VI.

Fig. 4. — Arraugemeut of the ai-teries at the upper ami lower pole. They eoiiie as sinsjle trunks from the main artery aud
run at an ans;le of 4.5° or more upward and downward to the vicinity of the "major ealices, where they divide into three branches.
I. Anterior branch.
II. Median branch.
III. Posterior branch.
The anterior and posterior branches are as a rule much lariter than the median.

Fig. 5 Variation of the median branch. Tliis brancli may be larsrer than usual and arise separately from the main artery at

points a and 6, or from the aorta direct (<•). It may be as lar^re as the renal artery itself, in which case it gives otf branches I aud
III or more. Such an arrangement of the arteries is as a rule associated with an ahnnrmal form and jiosition of the renal pelvis.

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE VII.

Fig. 6. The renal vein and the relation of its branches to

the pelvis of the kidney.

A. Anterior view of the left kidney. For tlie sake of
clearness the small veins of the cortex of the anterior portion
of the kidney have been omitted.

15. Transverse section seen from above. There is no col-
lecting vein posterior to the pelvis; all tlie veins of the
posterior region cross over to the anterior portion between
the necks of the minor calioes (b) to .ioin the veins of the
anterior region at a point indicated by c

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE VIII.

\;>^-

THE JOHNS HOPKINS HOSPITAL BULLETIN. JANUARY. 1901.

PLATE IX.

-*-. ■ .^

CNI

"'7 JJW"* * ... "^

-i-

i.y::M''H

-;',v<!*t^

<r'

EC —

CO -—

^ — o -

^ 72 i- ?; jj

O) 5 U "" T*

■^ ii s ^

^H ^ o - C

.2 = ^ < ^

33 -

2 -^ <: 23 o

THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1901.

PLATE X.

Fig. 1(1. — I'osteriov view of left kidney, slmwiiii;' inelliod of cxnlciriiii;
and opening the pelTJs. Tlie lower diagram indicates the direction of
the incision in relation to the papillae of the posterior pyramids.

Fig. !>. — A. Lateral view of left
Uidney, showing the location of the
most advantageous incision through
the parenchyma in kidneys which have
a normal arterial arrangement.

(!«' Lateral convex border of kidney.

bh' Position of lateral column of
cortical substance containing the ves-
sels.

<rc' Best incision.

B. (le Incorrect direction of ineisii>n.
I'x Correct direction of incision.

Fio. 11. — Imaginary trans-
verse section through a
kidney similar to Fig. !l B,
showing manner of ])lac-ing
the mattress sutur-e^.

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

vessels of the kidney (three-fourths nf the arteries and all
of the veins) are found (see also Figs. 3 and 6).

As was said before, in lobulated kidneys this column is
indicated as a distinct depression on the surface. Tlie cap-
sule seems thickened along this line and frequently iovm^
a whitish band, to which the perirenal fat a])pears to bo
more intimately attached than elsewhere.

Lobulation of varying degrees of distinctness is found in
the great majority of cases. The trained eye can detect this
lobulation in kidneys which a novice would pronounce per-
fectly smooth. Should, however, the kidney present not the
slightest depression or lobulation, the arrangement of the
large stellate veins of the capsule will still serve to suffi-
ciently locate the limits of the pyramids and the position of
the important lateral longitudinal column (6 b', Figs. 7 and
8). These veins are found to be more conspicuous and are
arranged in rows along the lines where the foetal lobulation
has been. (See Fig. 7.)

The Incision and Sithsequenl Suture. — The above described
landmarks should suffice to guide the surgeon in making his
incision so that the kidney can be readily opened between
its anterior and posterior arterial branches.

Fig. 9 A shows the lateral view of the kidney; a a' repre-
sents a line showing the lateral convex border; h h' indicates
the position of the lateral longitudinal column bearing the
large vessels; c c' is the line along which an incision should
be made. Diagram B shows the direction in which the
knife should pass. An incision through the middle of the
kidney {d e), would be inadvisable, inasmuch as it would cut
through large vessels in region / and would fail to open
the posterior caliees. The proper direction is indicated by
c X, the knife remaining in tlie posterior half of the kidne^'.
The cut should be made anteriorly to the posterior papilla?
(p) in order to avoid severing the collecting tubules of the
posterior pyramids. It is advisable to palpate if possible
the vessels and the pelvis at the hilum before making the
incision, and if their arrangement is found to be normal, ;'. e.
the pelvis at the posterior region "of the hilum and the great
majority of vessels anterior to the pelvis, then the above
described procedure is applicable.

I wish to add a few suggestions as to the incision itseli
and also as to the subsequent suture.

A short incision is made into the lowermost posterior
calyx if possible by means of blunt dissection (Fig. 1 A 7),
and through this incision the pelvis is explored. In a col-
lapsed state of the renal pelvis it may be difficult to enter
one calyx. In such cases a moderate distention of the pelvis
with sterile water or boric solution will facilitate the pro-
cedure considerably. If this short incision does not prove
satisfactory, the three caliees (3, 5, 7) should be carefully
opened by means of an incision from within to the surface
(Fig. 10). A curved knife will best answer this purpose.
A glance at Fig. 3 A shows that short transverse incisions
through the anterior or posterior parenchyma may produce
little hemorrhage, provided they do not come too near the
hilum. However, such incisions never open the pelvis satis-
factorily.

The arrangement of the vessels in the kidney suggests
the mattress suture as best adapted for approximating
the two cut surfaces. Simple interrupted sutures almost
always tear the tissues and produce an insufficient union.
The mattress sutures are placed at right angles, or nearly
so, to the large vessels and thus effectively prevent any
tearing of the kidney substance. If the bight of the suture
be 1^ to 2 cm., no strangulation of kidney substance should
result. The sutures should be applied in the manner repre-
sented in Fig. 11.

I. The pelvis is approximated with fine catgut sutures (a).
These ought to be placed between the caliees and take in
only the fat, the outer fibrous coat and the muscular layers.
The mucous membrane should not be included.

II. The second system of sutures should also be of catgut
and should unite the region of the papillae. They should bo
mattress sutures (Fig. 11 6) and are best placed by means
of a long straight three-cornered needle with a blunt point,
so that no injury to the large vessels results. A possible
oozing would only serve to tighten the grip of these sutures
and thus render them more effective.

III. The third system of catgut sutures should also be
mattress sutures and be placed parallel to the second through
the cortex near the bases of the pyramids (Fig. 11 c). Occa-
sionally the third system of sutures is superfluous.

IV. The capsule is then closed in the usual manner (Fig.
lid).

NOTES ON AEROBIC SPORE-BEARING BACILLI.

By W. W. Ford, M. D., D. P. H.,
Felloiv in Pathology, McGill University. Montreal.

{From the Mnhnn Pathological Laboratonj.)

The presence of spore-bearing bacilli in the contents of
the intestinal tract — in the normal organs and in various
serous exudates — is of fairly frequent occurrence in routine
bacteriological investigation, but the identification of such
micro-organisms does not always present that ease which is
requisite for the convenience of the routine worker.

Aside from the well-known forms of Bacillus subtilis and
Bacillus mesentericus, other varieties of spore-bearing bacilli
are recognized with difficulty, owing to the inadequate de-
scriptions usually found in text-books devoted to bacteri-
ology, where the pathogenic bacteria naturally receive the
greatest attention.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

During the past year a number of such forms have been
isolated and studied in the Molson Pathological Laboratory
and an attempt has been made to group these forms together,
using as a basis of classification the table of constant char-
acters recently adopted by Fuller and Johnson.

The various reactions of these bacilli on the usual culture
media have been estimated in so far as possible with refer-
ence to the possession, or lack of possession, of any of these
constant characters, and the results of this study are em-
bodied in the chart which accompanies this paper. Some
varieties here described may be identical with bacilli already
referred to in the literature, but an attempt to recognize them
positively has not met with success, and on this account they
have been looked upon as either new species or new varieties
of old species.

While such a description as this may at first seem inade-
quate, experience has shown that morphology alone fails to
reveal the identity of our ordinary micro-organisms and that
such a chart, as the one here utilized for bacteriological proto-
cols, is of the greatest assistance in species differentiation.

These spore-bearing bacilli were isolated at various times
in the laboratory under the ordinary conditions of aerobic
cultivation and are purely aerobic or facultative anaerobes
in character. They may be divided into two groups — patho-
genic and non-pathogenic — in each group being included
here five different varieties. The criterion of pathogenicity
is in all cases determined by the intraperitoneal inoculation
of a mouse with a 1 ce. dose of a 24-hour old culture of the
bacillus in question.

The members of both groups grow with ease on the routine
culture media, the production of spores taking place rapidly
under the usual conditions, a greater abundance of spores
naturally being observed on the older cultivations. These
bacilli possess certain characters in common: The carbohy-
drates are never fermented with the production of gas; milk
is coagulated, probably by the action of enzymes, as tli.
reaction remains neutral or alkaline until after the digestion
of the casein when a small amount of acid is produced. The
liquefying powers of these bacilli are especially well marked,
often casein, gelatin and blood serum alike being affected.

While the correlation of different biological properties in
bacteriology has as yet met with rather indifferent success,
yet it is a significant fact that marked liquefying powers are
often associated with the capacity of spore-formation. Simi-
lar deductions cannot be drawn with regard to motility, which
occurs, one might say, almost at random and cannot be asso-
ciated with other characters, as for example, pathogenicity.

The growth on potato is usually very abundant, this growth
serving at times as a diagnostic feature. The present status
of our knowledge of the conditions under which indol and a
faecal odor are produced, does not permit any reliable data
to be drawn from these reactions, but their importance,
when given, renders their careful study necessary.

Under Group 1, pathogenic spore-bearing bacilli, have been
included five different varieties:

Bacillus 4 is a capsulated bacillus which bears some re-

semblance to Bacillus mucosse capsulatus, but differs in so
many reactions, especially in its capacity to form spores,
that it has been placed in this group. It was isolated from
the liver of a healthy rabbit. Its morphology is that of
long rods with square-cut ends in fresh cultures, the bacillus
appearing singly or in short chains. In old citltures it loses
its characteristic form, appearing as chains of short oval
bacilli with the phenomenon of polar staining especially
well marked, two small retractile granules being seen at
either end of each individual. The capsule is apparent with
all dyes, hut it is most readily observed when the bacillus is
found in the tissues of an inoculated animal when the or-
ganism itself appears in its original character as a long
straight bacillus staining deeply and regularly throughout.

Bacillus A is non-motile, forms a characteristic scum on
fluid media, liquefies gelatine, coagulates milk without acidi-
fying or digesting the casein. It is pathogenic to mice,
guinea-pigs and rabbits, all of which died in from 24 hours
to 10 days, revealing at autopsy no special appearances
beyond those seen in infections in general and furnishing
pure cultures of the bacillus from the internal organs.

Old cultures of this bacillus — from which, by the way, a
peculiar sickening odor is obtained — will kill even as large
animals as rabbits in two hours, the animals dying with all
the symptoms of profound toxsemia.

Bacillus B was obtained from the kidney of a healthy
rabbit and in its morphology is not unlike the preceding
variety. It is a long bacillus with square-cut ends — without
a capsule — in old cultures growing out into degenerate forms,
showing the greatest diversity in morphology. Spore-forma-
tion occurs with great rapidity.

Bacillus B is non-motile and does not form a scum on
broth, liquefies gelatin, coagulates milk, digesting the casein
and producing an acid reaction. It is pathogenic to mice
and guinea-pigs, which survive from 24 to 72 hours, but is
not pathogenic to rabbits.

Bacillus C was obtained from the same kidney which fur-
nished the cultures of Bacillus B. It is a long, narrow
liacillus witli rounded ends, quite regular in shape and main-
taining its regularity even in old cultures. Its growth is.
somewhat slower than most of the spore-bearing forms.

It is actively motile in 24-hour old cultures, forms a
pellicle on broth, liquefies gelatin and blood serum, coagu-
lates milk and digests the casein with the production of an
acid reaction. It is pathogenic to mice, guinea-pigs and
rabbits, the animals succumbing in from one to three days,
and showing the presence of the bacillus in large numlicrs in
all of the internal organs.

Bacillus D was obtained from a rabbifs kidney. It is a
long, thick bacillus growing at times in short chains; it
exhibits polar staining to a marked extent, peculiar un-
stained areas often being visible in the bodies of the bacilli.

It is actively motile, liquefies gelatin, casein and blood
serum, but does not produce acid or coagulate milk. It is
pathogenic to mice and guinea-pigs, these animals dying
after a lapse of from 12 to 15 days, the characteristic organ-
ism being then obtained f ron^ the different organs.

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Bacillvs E is a large bacillus obtained by Dr. Yates from
a pleural exudate, which in its morphology cannot be posi-
tively distinguished from the preceding forms. Its varied
reactions on culture media testify to its originality. It
grows as a pellicle of broth, liquefies gelatin but not blood
serum, and coagulates milk, digesting the casein. Mice are
killed by intraperitoneal inoculation in from 3 to 4 days.

Prototypes of spore-bearing bacilli which are non-patho-
genic are Bacillus mesenterieus and Bacillus subtilis —bacilli
which are jirobably the most common forms of laboratory
contamination. For completeness in the chart the reaction?
of these bacilli have been either estimated or adopted from
Fuller and Johnson. With these, however, may be grouped
three other bacilli:

Bacillus F was obtained from the liver of a guinea-pig.
It is a thick, plump bacillus, at times in short chains, regular
and deeply staining. In its morphology it is somewhat simi-
lar to mesenterieus but is rather smaller than the potato
bacillus, from which it ditfers, moreover, in not forming a
wrinkled growth on agar nor a pellicle on broth, and in not
growing in the closed arm of the fermentation-tube nor
producing a faecal odor.

Bacillus G, isolated from the stomach contents of an
autopsy subject, is evidently a variety of Bacillus mesen-
terieus which it closely resembles in morphology but is dis-
tinguished by liquefying only gelatin and casein, not bloo.l'
serum, and by its failure to give a characteristic growth on

potato.

The last member of this group, Barillus II, was obtained
by Dr. Nicholls from the liver of a healthy cat. It is the
only one of this group which is non-motile and is distin-
guished from the other members by not forming a scum on
broth, in not causing a wrinkled growth on agar and in not
growing in the closed arm of the fermentation-tube. It
liquefies gelatin and blood serum, coagulates milk, digesting
the casein and producing an acid reaction.

It is hoped that this plan of description of bacteria may
prove of value to observers in different laboratories, and
should its adoption be brought about in different universi-
ties, a considerable advance can be made in settling the
complex problems of species differentiation.

Note: — Several of the bacteria here described are said to be faculta-
tive anaerobes in character but without the capacity of growing' in the
closed arm of the fermentation-tube. The latter reaction has been
utilized as a criterion of anaerobic j^rowth by a number of observers, it
being maintained that the growth of the organism will exhaust the
oxygen from the open bulb leaving an o.xygen free medium in the closed
arm, in which the facultative anaerobes will always grow. This apparent
contradiction in reaction is difficult of explanation unless one considers
that certain bacilli, aerobic and facultative iiuaerobes in character, grow
with greater avidity in a medium which has free access to oxygen thus
being attracted to the open bulb of the fermentation-tube, where they
grow luxuriantly, yet nevertheless being capable of development in an
atmosphere devoid of this substance, as is proved by cultivation in con-
ditions suitable for anaerobic growth. Compare in this connection the
chart of Fuller and Johnson where the Bacillus annulatus of Wright is
described as a facultative anaerobe and yet failing to grow in the closed
arm of the fermentation tube.

Bku

IGV.

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Note.— Tlie media hero employed were prepared according to the directions given in the 1897 report of the Committee of American Bacteriologists with the
exception that the reactions have been rendered neutral to plieuol-phthalein. The plus and minus signs have also been used in the manner directed by
this Committee.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

SUMMARIES OR TITLES OF PAPERS BY MEMBERS OF THE HOSPITAL AND MEDICAL SCHOOL
STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.

Simon Flexnee, M. D. Nature and Distribution of the
New Tissue in Cirrhosis of the Liver. — University Medi-
cal Magazine, November, 1900.

Andrew H. Whiteidge, M. D. Eeport of a Case of Tetanus
with Eeeovery. — Philadelphia Medical Journal, October
20, 1900.

William W. Foed, M. D. Venous Thrombosis in Heart
Disease. — Philadelphia Medical Journal, November 17,
1900.

William Sydney Thayee, M. D. Observations on the
Blood in Typhoid Fever. — Journal of the Bodon Society
of Medical Sciences, Vol 5, No. 1, 1900.

RoBEET L. Kandolpii, It. D. Ossification of the Choroid
Leads to the Identification of the Body in an Insurance
Case. — Journal of the American Medical As.^ociation,
November 10, 1900.

HuNTEE RoBB, M. D. Jlemarks upon the Post-Operative
Treatment; with Especial Reference to the Drugs Em-
ployed in 114 Consecutive, Uuselected Abdominal Sec-
tions without a Death. — Cleveland Medical Gazette, Octo-
ber, 1900.

Adelaide Dutcher. Where the Dnnger Lies in Tuber-
culosis.— Philadelphia Medical Journal, December 1,
1900.

William Osler, M. D. On the Study of Tubennilosis.—
Philadelphia Medical Journal, December 1, 1900.

J. Hall Pleasants, M. D. A Case of Acromegaly in a
Negro Associated with a Low Grade oE Giantism. —
Maryland Medical Journal, December, 1900.

Andeew H. Whiteidge, M. D. The Importance of Instruc-
tion in Medical Schools upon the Modification of Milk
for Prescription Feeding. — Maryland Medical Journal,
December, 1900.

Thomas R. Brown, M. D. A Review of Some of tlic Recent
Work on the Physiology and Pathology of the Blood. —
Maryland Medical Journal, December, 1900.

J. H. Mason Knox, Ph. D., M. D. Compression of the
Ureters by Myomata Uteri. — The American Journal of
Obstetrics, September and October, 1900.

Twenty-five cases are collected from the literature and the
gynecolog-ical records of the Johns Hopkins Hospital in which
myomata uteri were found to have exerted more or less pressure
upon one or both \ireters. The small number of such cases re-
ported is probably due to the fact that moderate grades of
ureteral compression from this cause produce few definite symp-
toms and the condition is consequently overlooked.

The cases are gathered in several groups according to the
severity of the ureteral and renal involvement; thus:

Group A. — Moderate ureteral involvement, 8 cases.

Group B. — I'ronounced ureteral pressure, 5 cases.

Group C. — Mechanical destruction of renal substance, 1 case.
Group D. — Ureteral pressure with inflammation, associated
with

a. Chronic nephritis, 2 cases.

6. Congenital cystic kidneys, 1 case.

C. Pyogenic infection, 2 cases.

d. Pyogenic infection, severe, '■> cases.

e. Kidney, a pus sac, 3 cases.

The several important features suggested by analysis of the
cases are then discussed. It is found that this ureteral com-
plication during- the growth of a myomatous uterus occurs
usually at middle life, that the tumor mass is usually large in
size and firm in consistency, and that although the pressure
upon the ureter can be exerted at any point or along much of
its course, the most frequent seat for compression is at the
pelvic brim. Of the complications the formation of adhesions
which often render operative interference difficult and the
secondary infection of the urinary tract are most important.
The pathology of the condition is brietiy referred to, l)eginning
with simple dilatation of the ureters and renal pelvis and pro-
gressing, unless relieved, to extreme grades of hydroureter and
hydronephrosis, or if the element of infection is added to, pyo-
ureter and pyelonephrosis. There are but few definite signs or
symptoms of the condition other than a partial retention of
the urine in advanced cases. Hence the diagnosis must be made
by a careful direct examination bimanually and with the cjsto-
scope through which the ureters can be catheterized when their
involvement is suspected.

Three lines of treatment are suggested: ((/) expectant, appli-
cable when the ureteral symptoms are slight and give no dis-
comfort to the patient; (6) palliative, permissible only when the
ureteral compression is moderate and is not becoming worse or
when the condition of the patient is so alarming as not to
tolerate a more radical method; (c) radical, that is, the removal
of the compressing- mass. This should be undertaken unless
contraiudicated whejiever there is definite indication that the
ureters are markedly compressed. The following conclusions
are drawn:

1. That some compression of the ureter is produced by a
large proportion of all large myomatous uteri.

2. The resulting liydroureter and hydronephrosis may con-
tinue for years and give rise to no discomfort to the patient.

3. The presence of a dilatation of the ureter and reiuil pelvis
however slight, lowers the resistance of these organs to toxic
and infectious agents, and hence infiammatory conditions of the
ureters and kidneys not infrequently follow ureteral compres-
sion.

4. This being the case in all instances of uterine myomata, the
possibility of ureteral involvement must be considered. When
such a condition is suspected every effort should be made by
means of direct examination, by ureteral catheter, etc., to arrive
at an accurate diagnosis.

5. Exploratory incision is occa.sionally justified to establish a
diagnosis.

6. The ureters should be inspected whenever the abdomen is
opened for the removal of the tumor.

7. A myomatous mass found to be exerting undue pressure
upon one or both ureters should be removed, if possible, unless
operative interference is contraiudicated.

8. Such serious sequelae of ureteral compression as extreme
hydronephrosis, pyelonephrosis, etc., should receive appropriate
treatment.

The references to the cases aud a table are appended.

Januakt, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

PROCEEDINGS OF SOCIETIES.

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

October 15, 1900.

The meeting vas called to order by the retiring president,
])r. Henry SI. Thomas.

Dr. Thayer presented resolutions expressing the feelings
of the Society at tlie death of Dr. Lazear, which were unani-
mously adojjted.

The annual election of officers was held and Dr. William
H. Welch was elected iiresident. and Dr. G. Brown Miller
secretar}', for the coming year.

Case of Astliiiia with Cyanosis, Extensive I'urpiira, I'aiiil'iil
Muscles, and Eosinopliilia. Dk. Oslkh.

This is an uniisual case in several respects. This young
man came in on the 3d of October complaining of pain in
the abdomen. His personal and family history are negative
so far as this present condition is concerned. He had eaten
abundantly of pork, and it is not known whether it was raw
or cooked, as he is a Pole and it is difficult to understand
him.

His present illness began with a chill, accompanied by
pain in the abdomen and on the three following days he had
nausea and vomiting. There was no diarrhoea. There had
been cough and expectoration since the onset of the illness
and he had been confined to bed. On the night of admission
the most remarkable feature noticed was a very deep
cyanosis. The respiration was somewhat labored, being
about 30 to the minute, but there was no urgent dyspncea.
There were numerous dry rales and much wheezing in the
tubes. He remained in this condition of remarkable cyano-
sis with practically no fever, except a slight one on the
third day; indeed, as a rule, his temperature has been sub-
normal. The cyanosis was extreme and with it, which is
noteworthy, he remained constantly recumbent.

On October 7, in addition to the cj^anosis, petechi;e
appeared over the body, first on the face and chest and then
over the skin of the entire body except the legs. Ho pre-
sented a unique appearance, so far as our experience here
is concerned, and looked very much like a case of malignant
hemorrhagic smallpox. A diflferential count showed 11
per cent of eosinophilesi On the 8th of October he showed
great tenderness of the muscles. The slightest touch on the
muscles of the arms or legs caused him to wince. . A portion
of muscle was excised and showed marked degeneration with
a great deal of fat in the fibres, but no trichina-. On the
9th his leucoeytosis rose to 52,000, the petechia- had in-
creased, his face was swollen, and he looked to be in a very
critical condition. He was, however, rational, apparently
comfortable and took his food fairly well. On the 11th the
eosinophiles had risen to 2.3 per cent. Yesterday the cyano-
sis began to disappear. Cultures from the blood are nega-
tive and there is no Widal reaction. There is a trace of
albumin and few arranular casts.

Of the groups of cases of cyanosis there is one in which
the air cannot get to the blood — the respiratory group; a
second group in which the blood cannot get to the air — the
cardiac; and there is a third group in which there are
changes in the hemoglobin, such as cases of poisoning by
carbon monoxide or the coal-tar products. There are three
conditions in which, in hospital practice, we see extreme
cyanosis with comparative comfort: First, the cases ot
chronic emphysema and asthma. A patient will come in
completely cyanosed, quite livid, and yet fairly comfortable
and not especially short of breath. Secondly, the cases of
congenital heart disease. Thirdly, the cases of antifebrin
arid antitoxin intoxication.

In this case there has been no methemoglobin in the
blood, and I think it cannot be regarded as belonging to
the toxic form. He has had some asthma and emphysema;
with that would agree the condition of eosiiiophilia. The
question is whether or not he has had a myositis and possibly
trichinosis. That cannot be determined until we have fur-
ther examined the muscle. (It is negative, too).

DlSCUSSION^.

Dh. Welch. — Are there any abnormal leucocytes, such as
are not normally found in the blood ?

De. Futcher. — No. There are many cells, however,
which it is difficult to classify, because it is hard to say
whether they are eosino])hiles or polynuclears; they seem to
stay in an intermediate stage.

Dr. Welch. — Dr. Osier spoke of the similar appearance to
black smallpox when the petechia were so abundant. It
has been claimed that the leucocytic count is quite charac-
teristic in smallpox; in fact, so definite in its pro] mrt ions
as to be a decided help in diagnosis.

Bisection of the Uterns in Hjsferectoniy. Dr. Kkli.y.

I See Bulletin- for January, 1901.]

Exhibition of Siirg-ical Cases. Dk. Mitchell.

Four cases of typhoid perforation were described, and one
of appendicitis. (To appear in full in a later number.)

Discussion.

Dr. Oslee. — This last case is exceedingly interesting, for
it is, if I remember rightly, the only case of abscess of the
liver in connection with typhoid that we have had in the
hospital. I have seen two such cases but it is one of the
rarest of all complications of the disease. The positive
Widal, the hemorrhages, the absence of ameba and the his-
tory make it quite clear as to the character of the original
disease.

Dr. Thayer. — I wish to ask, referring to the case in which
the appendix was removed, how long before death the last
rise of leucocytes was observed; whether it was, as the
Germans say, due to the death agony or to something else.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

Dr. Mitchell. — It was several hoars before death.

Dr. Keen in his remarks upon surgical complication^
speaks of 21 eases of liver abscess with two recoveries.

De. Welch. — I remember seeing one case of a somewhat
different type, which occurred before the days of making
cultures, in which there were thrombosis of the intestinal
mesenteric veins nnd multiple metastatic abscesses through-
out the liver instead of one large abscess.

Dr. Oslee. — I think there is one point that ought to be
quite clear in reference to the condition of the peritoneal
surfaces of typhoid ulcers. Such a condition as that de-
scribed by Dr. Mitchell does not indicate that perforation
has of necessity occurred in those ulcers. Every deep ulcer
is sure to have a great deal of injection about it, or even
lymph on it, and sometimes in very intense and severe cases
that come to autopsy at the end of the second week you ea;i
count through the serosa every Peyers patch that is in-
volved. I do not think, therefore, that it would be right to
say, even with the most intense swelling and redness, that i:
necessarily follows such an ulcer will perforate.

Report of Cases from the Garrett Hospital for Children. Dr.

W. B. I'LATT.

a) Bow-Leg, b) Knock-Knee, c) Epispadias. Patients
shown in each case with photograph of condition previous
to operation.

The cases of bow-leg and knock-knee are presented to-
gether to illustrate the opposite conditions. We know that
infants at birth, and also long before they have borne pres-
sure upon the limbs at a later date, present bow-legs. These,
as well as the bow-legs acquired after walking, often become
straight spontaneously. What chiefly interests us is, what
to do if this spontaneous straightening does not occur. If
spontaneous correction does not take place before the age of
four years, or if orthopedic appliances properly applied do
not accomplish the purpose before that age, there is little
reason to hope for further improvement without operation,
on account of the hardening of the bones that quickly ensues
in such cases.

In bow-leg we have to deal with a general curvature of
the femur, tibia, and fibula, which is accentuated at certain
points. This curvature is always more or less outward, and
often forward as well.

The extreme curvature is doubtless due chiefly to the
weight of the body upon softened bones, and in but slight
degree to muscular tension.

Eickets is clearly the cause of the softening in the greatest
portion of cases. If knock-knee (like bow-legs) be due to
rickets we would exjiect an inward curve instead of the
angle which we find. Here we have a disproportionate
growth of the inner portion of the lower end of the femur,
sometimes also of the upper end of the corresponding part
of the tibia. A practical point is, that in extreme bow-leg
we find flat foot, whereas in extreme knock-knee we fre-
quently get an acquired club foot.

The gait in the two classes of cases is exactly the reverse,

the one of the other. The two patients here shown arc
each five years of age. The " bow-leg " is somewhat defi-
cient mentally. The deformity in the latter case was reme-
died by dividing the tibia nearly through, near the middle,
with a chisel, proceeding from the anterior and inner aspect,
outward. The bone was then fractured at this point, and the
leg straightened. The fibula fractures with the tibia. The
entire limb was now put up in plaster for three weeks. The
usual result is an entire success. After both knock-knee
and bow-leg osteotomies, there is a good deal of oozing, and
the plaster bandage is not infrequently stained through.
If the operation has been performed aseptically, there is
never any trouble.

Osteotomy for knock-knee is performed on a different
plan and in a dift'erent place. Mackewcn's place of election
is three-quarters of an inch above the adductor tubercle on
the inner aspect of the femur. The chisel is driven about
two-thirds of the way through the femur, going upward and
downward after entering the chisel, so as to divide the
anterior and posterior aspects of the bone. After with-
drawing the chisel the limb is forcibly straightened. This
impacts the lower fragment into the upper, and chiefly on
the innermost line of the division. The undivided part of
the bone bends like a hinge without fracture. The limb is
immediately put up in plaster in a slightly over-corrected
position.

In both the above cases, I operated upon the right limbs,
while Dr. Cone operated upon the left knock-knee, and Dr.
Ratcliffe upon the left bow-leg.

e) Epispadias. The patient, W. L., is twelve years of age.
He has been operated upon six times during the past seven
years. Five operations are theoretically called for, but one
or more of them usually have to be repeated. The series of
operations devised by Prof. Thiersch are the best in my
opinion. First of all a penis must be Snade, as it is now a
rudimentary affair, consisting of little more than a button,
drawn up close to the pubes, the imperfect glans penis
almost in contact with the hole which is directly over the
deep urethra, and in contact with the pubes.

The first operation is to divide both corpora cavernosa
subcutaneously, with a tenotome, close to the pubes. The
penis is then drawn out and bound down with bandages for
several weeks until it keeps more nearly to the normal posi-
tion. After waiting for three or more months the second
operation is done by sinking the urethra into the body of
the glans and covering it in. Again a wait, when the third
operation is perfoi'mod by covering in the urethra on the
shaft of the penis by superimposed skin flaps. The fourth
procedure is to buttonhole the apron of skin below the
glans, thrust the latter through it and fasten the edge of
this new foreskin to the posterior margin of the glans and to
the anterior edge of the new urethra in the shaft. After
another wait, the last operation is done by closing the open-
ing into the urethra close to the pubes by superimposed flaps,
one of denuded skin, and one of skin only, from the pubic
region.

January, 11)01. |

JOHNS HOPKINS HOSPITAL BULLETIN.

In all these operations the difficult thing is to get the
flaps to unite urine-tight, and without loss of substance.
The last one is the most difficult to bring to a successful
result. The final results in tliese cases, at best, are lilce the
noses made by rhinoplastic operations, not beautiful; but wo
are thankful if they arc useful, and the patient is able (o
hold his urine night and day instead of constantly dribbling,
or losing urine on the slightest provocation, thus saturating
his clothing, and making him unendurable to himself and
to others. The increasing control of the sphincter with the
successive operations until complete control is reached, is
interesting.

A very clean operation, dry dressings, and a very faithful
nurse are absolutely necessary to success.

The Relation of CUolelitliiasis to Disease of the Pancreas and to
Fat-Necrosis. Dr. Opie.

The patient wliose history I shall relate was admitted to
the service of Dr. Osier complaining of pain in the abdomen
and fever. His family history is unimportant. lie had
suffered frequent attacks of indigestion characterized by
pain after eating and, rarely, by nausea and vomiting. Six
months before his fatal illness he had had an attack of
jaundice which lasted three weeks and was accompanied, by
severe abdominal jiain and some fever. The jaundice dis-
appeared and he remained in good health until the begin-
ning of this illness. He was suddenly attacked about nine
o'clock one night with very severe abdominal pain followed
by nausea and vomiting. The vomiting continued through-
out the night but subsequently was not severe. The pain
was great for about four days but became less severe. On
the seventh day of his illness, tenderness and swelling ap-
peared in the right hypogastric region. Jaundice was not
noticed previous to his admission to the hospital. His tem-
perature ranged between 100° and 103°.

He was admitted to the hospital on the eighteenth day of
his illness and the note made by Dr. Futcher shows that he
was a large well-built man with a sallow complexion; the
conjunctivaB had a very slightly yellowish tint. Examinntion
of the chest was negative. On inspection of the abdomen
a distinct prominence was noticed in the right hypogastric
region extending into the right half of the umbilical with
its lower margin at the level of the umbilicus. The urine
at this time contained no sugar and its specific gravity was
1.017. His condition remained unchanged for two days, but
on the night of the third day he became restless and de-
lirious and his temperature rose gradually to 104° ; the white
blood-corpuscles numbered 19,500. The patient was trans-
ferred to the surgical side where the diagnosis of acute
pancreatitis was made by Dr. Bloodgood and an operation was
performed. An abscess was entered through an incision in
the great omentum between the stomach and transverse colon.
The cavity contained dark fluid, in which were necrotic ])ar-
licles. A drainage tube, packed about with gauze was in-
serted into the wound. There was a considerable amount of

discharge from the wound. The patient did not rally from
tlie operation and died at the end of four hours.

An autopsy was performed a few hours after death. The
skin surface was not jaundiced though the conjunctiva; had
a yellowish tint. On opening the abdomen, the omentum,
lightly adherent in the neighborhood of the wound, was
foimd to contain a great quantity of fat. Studding this fat
were conspicuous opaque white areas, about 3 mm. in diam-
eter and extending below the surface not more than 1.5 mm.
Similar areas were present in the fat of the mesentery, in
that of the abdominal wall below the peritoneum over the
bladder and in the fat in front of the kidneys. The pre-
served specimen here exhibited shows these areas of necrosis
very well. The abscess which was entered at the time of
operation was found to occupy the site of the lesser omental
cavity and contained about 500 cc. of dark fluid in which
were necrotic solid particles. Its wall was black and necrotic
in appearance but on cutting into it the dark discoloration
was found to extend only a short distance and gave place to
opaque white areas of fat-necrosis. Projecting from the
posterior wall of this cavity was a large projecting mass
lying to the right of the descending portion of the duodenum,
extending toward the spleen. It was composed of dark
reddish-black material, was spongy in texture and suggested
changed blood. The pancreas lay beneath it and was in
large part well preserved. The gall-bladder contained a large
number of faceted calculi (about 100) of an average diameter
of 1 cm. In the common duct, 1.5 cm. from its origin, was
a similar calculus. At this point the pancreatic duct was
separated from the common bile-duct merely hy a thin
membranous septum, and it was upon this septum that th(-
gall-stones lay.

Microscopic examination shows that the interstitial tissue
of the pancreas is thickened and contains many cells in
which are brownish-yellow pigment granules giving the reac-
tion of iron. The necrotic material lying upon the surface
of the pancreas is found to be changed blood. Cultures
made from this necrotic material in the wall of the abscess
were studied by Mr. P. H. Bassett ; they contained the Bacil-
lus coli communis, proteus vulgaris and lactis aerogenes.

The changes in the pancreas show that hemorrhage had
occurred into and about the pancreas sometime before death.
In the common bile-duct was lodged a gall-stone in such a
position that it might readily compress the pancreatic duct
and give rise to changes in the pancreas.

The relations of the pancreatic and common bile-duets
are well known. Tliey lie in contact for a distance of about
2 cm. and one can readily imagine that a gall-stone lodged
near the orifice of tlie common duct might compress the
pancreatic duct. In about two-thirds of all bodies the two
ducts of the pancreas anastomose within the gland, while in
the other third there is no anastomosis, and should a gall-
stone, lodged in tlie common bile-duct, compress the duct
of Wirsung, the pancreatic accretion would be forced back
upon tlie gland. When the common bile-duet is obstructed,
the obstruction to the gall is readily shown by the yellow

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

color of the bile pigments which escape into the tissues, but
when the pancreatic duct is obstructed the results are not so
evident. Nevertheless, the condition of fat-necrosis gives
evidence of the escape of the pancreatic secretion. The
essential feature of this necrosis of fat is the splitting of
the fat into its fatty acids and glycerin and numerous
experiments have shown that if one produces a lesion of the
pancreas which causes the pancreatic juice to escape into
the tissues, necrosis of fat results.

In a series of experiments ' performed upon cats, I ligated
both ducts of the pancreas and at the end of about three
weeks a very wide-spread necrosis of almost the entire ab-
dominal fat, and to a less extent of the pericardial and sub-
cutaneous fat as well, resulted. If, however, the ducts be
ligated and pilocarpin be administered in order to stim\ilate
the secretion of the gland, similar wide-spread necrosis
occurs within four days, showing that the escape of the
pancreatic juice is the essential feature. Where we finil
necrosis of the abdominal fat, we may assume that some
lesion of the pancreas has allowed the escape of the fat-
splitting ferment of the pancreatic secretion into the sur-
rounding fatty tissue.

I have examined the literature of acute pancreatitis and
fat-necrosis to determine the possible relationship of chole-
lithiasis to acute lesions of the pancreas, and I have found
thirty-two cases in which such lesions were associated with
the presence of gall-stones demonstrated by autopsy. Gall-
stones, as is well known, are very frequently found at autopsy
and maj^ have caused no symptoms during life. It is there-
fore necessary to show that their presence bore some rela-
tion to the acute pancreatic lesion. In eight of the collected
cases a gall-stone was actually lodged in the common duct
near its orifice or had escaped from this position and lay in
the duodenum. In five of these cases there were hemor-
rhagic lesions of the pancreas; the gland was enlarged and
the interstitial tissue was infiltrated witli blood. In the
absence of microscopic examination it is impossible to say
whether the lesion was a simple hemorrhage or a hemor-
rhagic inflammation. Four of the cases are particularly
interesting, since death resulted within forty-eight hours
from the onset of symptoms; the sudden onset of pain in the
abdomen with nausea and vomiting was followed by collapse
and death within forty-eight hours.

In three cases the symptoms noted above were followed
by death within forty-eight hours. At autopsy the pancreas
was infiltrated with blood; the gall-bladder contained calculi,
but the one which had caused the fatal attack had escaped
into the intestine and was not found. In one additional case
a gall-stone had found its way into the duct of the pancreas.

There is another group of six cases in which the relation-
ship of the pancreatic lesion to cholelithiasis mav also be
established. The duration of the fatal illness is longer and
the symptoms are definitely those of gall-stone lodged in

' Contributions to tlie Science of Medicine, dedicated to W. H. Welcli.
p. 859, 1900.

the common duct; e. //., pain and jaundice. At autopsy the
diagnosis of gall-stone colic is confirmed by the presence of
niunerous calculi in the gall-bladder, but none are found in
the duets. It is not surprising that with the longer duration
of the case the stone causing the trouble should have escaped
into the intestine. In the former group it has been seen
that a stone lodging only forty-eight hours might produce
an intense hemorrhagic lesion. In these cases of longer
duration there is usually evidence of previous hemorrhage;
the organ is the seat of gangrenous inflammation and lies in
an abscess limited to the lesser peritoneal cavity.

In fourteen cases the relationship could not be so definitely
established. Though symptoms of gall-stone colic were
present, the stone was not found lodged in the duct, nor was
jaundice present. The changes in the pancreas resembled
those in the previous cases, and it seems probable that in
most of these cases the pancreatic lesion was a result of the
lodgment of a gall-stone in the conunon duct near its orifice.

In twenty-six of the thirty-two cases fat-necrosis was
present.

Discussion.

De. Thayer. — Two of the cases to which Dr. Opie has
referred I reported ten years ago. The men had had re-
peated attacks of gall-stone cholic and finally one very sharp
attack with intense abdominal pain, sudden unaccountable
collapse and death within forty-eight hours after the first
symptoms. Aiitopsies showed acute hemorrhagic pancrea-
titis with, I think, evidences of older hemorrhages than
those associated with the fatal attack, suggesting the possi-
bility that with earlier attacks there had been some pan-
creatic trouble.

Dr. Welch. — By this communication Dr. Opie has added
another valuble contribution to his important series of
papers dealing with the histology and pathology of the
pancreas. His previous experimental work has enabled him
to come to a clear and satisfactory interpretation of his own
and others' observations of the influence of gall-stones in the
causation of various forms of pancreatic disease. Without
this basis of experimental work this relationship of gall-
stones to diseases of the pancreas could not have received so
complete an explanation.

In this connection I wish to call attention to the import-
ance of occlusion of excretory channels and ducts in favoring
infection. This can be observed not only with the pan-
creatic and biliary ducts, but also with the urethra, ureter,
salivary and other ducts opening upon exposed surfaces
normally carrying bacteria. As Dr. Opie's experiments have
shown, the damming back of the pancreatic secretion and its
escape into surrounding and distant parts cause multiple fat-
necroses and anatomical changes in the pancreas. Some-
times infection participates in these changes and modifies
the conditions. The first recorded observation of the inva-
sion of internal parts of the human body by the colon bacil-
lus w'as the case of multiple fat-necrosis which I reported
to the Association of American Physicians in 1890. In the
class of cases considered in Dr. Opie's paper we have to

Januakt, 1901. J

JOHNS HOPKINS HOSPITAL BULLETIN.

reckon in the first instance with the obstruction to the out-
flow of the pancreatic juice^ and in the second place, as a
frequently important factor, with the invasion of bacteria
in consequence of such obstruction.

Noreiiiber 5, 1900.

Dr. Welch in the chair.
Secondary Syphilitic Eruption. Dk. Fu'ichkk.

Case 1. — The patient, a woman aged 34, was admitted on
the medical side, October 17th, having previously been in the
gynfficological ward since September 28th. Two weeks prior
to her entrance into the hospital she liad been complaining of
pelvic pain, and after an examination the diagnosis of double
salpingitis witli a cystic ovary was made. The operation
of vaginal puncture was performed October 1st and the cyst
evacuated. I am indebted to Dr. ]Miller for permission to
speak of the patient's condition while on the gynfficological
side. She had had a slight fever previous to the operation,
temperature going up to 101°, but contrary to expectation
the temperature did not come down after operation but con-
tinued to rise until on October 3d it reached 103.3°. On
that day she had a slight erythema of the skin and it was
thought possible it might be some acute infectious disease.
The following day Dr. Miller asked me to see the case witli
him but, though the eruption was still present, it was rapidly
disappearing and seemed to have been nothing more tlian a
temporary erythcjna. Tlie patient was transferred, how-
ever, to the isolation ward to ])revent any trouble in case
our opinions should prove incorrect. The temperature then
fell nearly to normal, being 99.3° on tlie morning of the 6th,
but later the same day it ran up to 105. -l". In about 4S
hours the temperature returned to normal and remained so
for nearly 48 hours, when another paroxysm occurred, during
which it reached 104.3°. It reached normal again in two
days and she had another slight paroxysm wliich was fol-
lowed subseq\iently by two other similar intermittent par-
oxysms.

The blood was examined on several occasions but no
malarial parasites could be found. The leucocytes were re-
peatedly counted but there was no leucocytosis. Physical
examination of all the organs was negative. We thought it
might possibly be one of those obscure cases of Hodgkin's
disease but there was no glandular enlargement. Her tem-
perature now fell to nearly noruuil and continued so. The
patient felt otherwise perfectly well and we allowed her to
go home on October 33d.

On the 30th of October she came back with a perfectly
typical macular, papular and pustular syphilitic rash on the
face, arms and chest. Dr. Gilchrist was asked to see her
then and diagnosed the case as one of secondary syphilitic
eruption. I saw the patient yesterday and, the skin lesions*
still being present, I hoped to present tlie patient to-night.
We found on investigating the history of the husband that
he admitted exposure on July 4th, a jirimary sore on August
11th and a definite secondary skin eruption on August 38th,

so there seems little doubt that in this case the temperature
which gave us a great deal of anxiety was due to the syphilitic
eruption.

A word or two in regard to such fevers may not be out
of place. In the first place, it may be of a more or less con-
tinuous type; secondly, it may be of a remittent type, the
temperature not reaching normal but remitting towards the
normal point; and thirdly — and these are the most interest-
ing cases — it may be of the typical intermittent type resem-
bling closely one of the forms of malarial fever. It may
precede the secondary skin eruption, as in this case, but
most commonly it occurs coincidently with the eruption.
It may occur, howeyer, during the course of either the
secondary or tertiary symptoms; the most common time for
it to Occur is at the onset of or during the course of the
eruption.

This case presents one of the unusual forms of inter-
mittent type and it is also of interest in that the fever came
on at least 27 days before the onset of the secondary skin
eruption.

A somewhat similar case is reported by Yeo in the British
Medical Journal for 1884. His patient had a fever with
daily exacerbations ranging over 5 or 6 degrees. It was of
a more or less continuous, persistent type, lasting for about
one month. It occurred between 25 and 30 days after ex-
posure and practically a month before the onset of the
secondary skin eruption.

This fever of syphilitic origin may also occur late in the
disease and Sidney Philips has reported a case that illus-
trated this very well. His patient was a young woman
married in 1879. Six months later she had definite secon-
dary symptoms and nine 3''ears subsequently developed a
tertian type of fever which lasted almost eight months. The
patient had definite chills at the onset of the paroxysms and
profuse sweats followed them. The fever was not influenced
by quinine but immediately disappeared on the administra-
tion of potassium iodide and mercury.

Case 2. In this case the cause of the fever is not so evi-
dent. A boy, 13 years of age, was admitted September 26th
complaining of pain in the arms, legs and back of the neck.
Five or six days previous to this he had a definite chill, which
was followed by a fever that continued up to the time of
admission. He looked well, but had a temperature of 104.3°,
and the joints, particularly the knees and elbows, were red-
dened and swollen. There was also a considerable degi'ce
of stiffness of the neck, and the head was rotated to the left
side. He did not have Xornig's sign, one of the important
symptoms of meningitis. He was started on the salicylates
and the next morning, his temperature having dropped to
96°, we thought possibly it was nothing more than a case of
acute rheumatism. The temperature went up again the next
day, however, and from that time on ran a very irregular
course, remitting at times and at others being definitely in-
Icrmittcut. The leucocytes have been persistently high,
ranging from 11,000 to 36,000. Lumbar puncture was done
on two or three occasions but with negative results. Blood-

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

cultures taken at different times gave no organisms until last
Saturday, when a coccus was found which has as yet not been
identified. The boy has had repeated attacks of arthritis
and at present there is some evidence of involvement of tlic
apex of right lung. What the nature of the case is, it is
difficult to say.

November 23, 19(i0. Au interesting development occurred
in this case on November 5th. On this date the highest
temperature reached was 104.9°. The mere possiijility of
the fever being syphilitic in origin was entertained, and
potassium iodide in 8 grain doses, three times daily, was
commenced. The next day the boy's temperature reached
normal and has remained so since. While we have not yet
obtained any positive evidence of lues in the boy or hi,-;
parents this therapeutic test is extremely suggestive.

Discussion.

De. Osler. — The question of intermittent fever in syphilis
is very interesting and was brought forcibly to our notice
here by a remarkable case. An army officer was admitted
with obscure symptoms after having been under treatment
in other cities for some time. He had rise of temperature
every day or every second day to 103° or 10i° without any
other symptoms. When he reached his ward the diagnosis
was ready, however, as he had then developed the eruption.

Last year we had an interesting scries of syphilitic fevers,
several of them occurring quite early in the disease, one a
markedly intermittent case and one a very continuous fever
during the early stage of the disease.

Observations on Blood in Typhoid Fever. Dr. Thayer.

(See Vol. VIII, No. XIX, Johns Hopkins Hospital Re-
ports.)

Discussion.

De. Welch. — The points brought out by Dr. Thayer con-
cerning leucocytosis in experimental bacterial infections are
particularly well illustrated in the infections of rabbits with
Micrococcus lanceolatus, as I found several years ago when
engaged in the study of this micro-organism. Every degree
of virulence may be possessed by cultures of this micro-
coccus obtained from different sources. With maximum vir-
ulence of the organism and high susceptibility of the animal,
death may follow experimental inoculation in 16 to 2-i hours.
In these eases there is progressive diminution in the number
of leucocytes up to the time of death. With less virulent
micrococci and greater resistance of the animal, death may
be delayed for several days. There are then usually inflam-
matory exudates at the site of inoculation and often else-
where, and now there is marked leucocytosis. Sometimes
the animal survives nothwithstanding evidence of severe
infection, and in these cases I found the count of the leuco-
cytes a valuable index to the probable issue of the infection.

Albumosuria. Dk. Hamburger.

(To appear in a later number of the Bulletin.)

November 19, 1900.

£xhibltiou of Patliolog-ical Specimens: Vegetative Gudocarditis,
Cystic Kidney, Carcinoma of Gall Bladder. Du. Mak-

SHALL.

The specimens I have to exhibit are a heart from one case
and a liver and kidney from another. The heart specimen
is particularly interesting. It is seen that two valves are
affected, the mitral and the aortic. Upon examining the
mitral valve, in addition to the fresh vegetations, one finds
several firm, organized vegetations along the line of closure,
and several of the chordae tendineffi are ruptured and thick-
ened. Attached to some of the chorda? are small nodules of
dense fibrous tissue. From this condition it is evident that
there has been a former attack of acute endocarditis from
which the patient has recovered.

There are no old vegetations on the aortic valve or on
the ventricular surface of the mitral valve.

The largest of the fresh vegetations are on the ventricular
surfaces of the posterior and left cusps of the aortic valves.
These vegetations have been somewhat injured in preparing
the specimen, but at the autopsy they formed a mass project-
ing about 2 cm. from the under surface of the valve. At the
base of the vegetation is a large ulceration through the left
aortic leaflet. From fliis most prominent lesion, a row of
small fresh vegetations extends up into the sinus of Valsalva,
and also dovni over the ventricular surface of the mitral
leaflet to its free border. A few small recent vegetations
are also present along the line of closure of the mitral valve.

From the extent of the lesion on the aortic valve, and
from the fact that the vegetations grow fewer and smaller
the further they are situated from the aortic yalve, it seems
probable that the acute endocarditis started on the aortic
valve.

In addition to the chronic and acute valve lesions there is
general cardiac hypertrophy and dilatation, and adherent
pericardium, and, finally, a moderate degree of fibrous myo-
carditis.

It may be noted that the orifices of the heart are of smaller
circumference than normal:

The aortic orifice measuring 6.5 cm.

The mitral orifice measuring 9.0 cm.

The pulmonary orifice measuring 8.5 cm.

The tricuspid orifice measuring 12.0 cm.

Dr. Harris found streptococci in coverslip preparations
and in cultures from the fresh vegetations, and in sections
stained by the Grara-Weigert method masses of cocci can be
seen at the edge of the vegetations. Nothing more of in-
terest was found at autopsy. No infarcts were discovered.

The most important recent work upon endocarditis that
I' have found is by Harbitz in the Deutsche medicinische
Wochenschrift, 1899, No. 8, S. 121-124.

He divides the endocarditides into infectious and non-
infectious, the latter associated with carcinoma or other
cachectic conditions.

Out of 43 cases of infectious endocarditis, Harbitz demon-

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

strated bacteria in 33, the relative frequency of various

organisms being:

Streptococci 39.5^ 17 cases.

Staphylococci 18.6;^ 8 "

Pneiimococci 11.6^ 5 "

Other organisms 6.9;^ . 3 "

No organisms 23.2^ 10 "

The 10 cases without organisms were cases of healed in-
fectious endocarditis, such as is seen on the mitral valve of
the specimen shown to-night.

Harbitz subdivides the infectious endocarditides into
pyffimic and non-pya?mic. He finds that the staphylococci
most often cause pyemic endocarditis, giving the clinical
picture of pyjemia and, anatomically, showing ulceration of
the valves and metastatic abscesses.

The non-pyaemic variety is usually due to the streptococcus
or pneumococcus. Of his 16 cases of this form of endocar-
ditis, in 9 Harbitz found streptococcus, in 4, pneumococcus
and in 2, an unidentitied organism.

In this group of cases the disease may last longer, and
the vegetations tend to be larger and to spread into the
auricles and ventricles. The emboli are not suppurative.
Harbitz does not consider this classification absolute, but
states that the same organism may produce any type of
endocarditis, from the mild vegetative to the pysmic, ulcera-
tive form.

The specimen shown to-night conforms more closely to
Harbitz's non-pyasmic type of endocarditis; the vegetations
show the streptococcus, they are very large, they tend to
spread quite widely, and there are no suppurative emboli.
The specimen approaches Harbitz's pysmic type in showing
ulceration of the aortic valve.

The other two specimens shown to-night are from an
autopsy performed a few days ago at Bayview. One is a
congenital cystic kidney, the other carcinoma of the fundus
of the gall-bladder, with metastases to the adjacent surface
of the liver and to the lymph-glands along the bile-ducts.

Discussion.

Dk. AVelch. — Dr. Marshall has referred to the interesting
observations of Harbitz of Christiania, who distinguishes
Staphylococcus endocarditidis from those caused by strepto-
cocci, pneumococci and other bacteria. According to Har-
bitz, staphylococci are the principal infectious agents in
acute ulcerative endocarditis, whereas the other micro-
organisms cause the more chronic and warty forms of endo-
carditis with non-suppurating infarcts, these latter forms
being the more common.

It would be interesting to analyze our cases with reference
to this classification of Harbitz. When some years ago I
went over our autopsy-protocols, I found that streptococci
first and pneumococci in the second instance were most fre-
quent in endocarditis, but staphylococci were occasionally
met, and in addition there is quite a long list of other bacteria
sometimes present in the vegetations, among the latter,
gonococci. Micrococcus zymogenes of MacCallum and deli-

cate, slender bacilli resembling the influenza bacillus being
of especial interest. I do not recall that staphylococci were
responsible for peculiarly malignant types of the disease,
and certainly streptococci were present in some of the in-
stances of genuine ulcerative endocarditis. The efforts to
associate definite species of bacteria with the various clinical
and anatomical types of endocarditis have upon the whole
yielded disappointing results, the same micro-organisms be-
ing found in the milder warty forms of the disease as in the
acute ulcerative varieties. In the light of Harbitz's con-
clusions it seems important to continue the studies along
these lines. One point is of interest, viz. : that emboli con-
taining streptococci may cause bland, or at least non-sup-
purative infarcts.

Congenital Absence of Pectoralis Major and .Uinor. Dr. Ru.sk.
(To appear in a later number of the Bulletin.)

Report of Gynaecolosical Cases. Dr. Miller.

Case 1. — Simple Ulcerative Colitis. — I intended to report
this case because I thought I had cured it by applications to
the lower part of the bowel, but since the program was
printed I have had occasion to examine her again and find
that the ulcers have returned. The patient was a young
woman, 25 years of age, who about 14 months ago began
to complain of diarrhoea. She had no nausea or vomiting
but the bowels wore moved from six to twelve times a day,
the stools being dark-colored and offensive. Her mother
and several other persons in the neighborhood who use the
same drinking water were affected in somewhat the same
way although not so severely. She was treated in the usual
way and, according to her statement, was kept in bed for
about six weeks, receiving medicines by the mouth, and
irrigations. She would improve somewhat but as soon as
she got on her feet again the diarrhoea returned.

She entered the hospital September 4th and was examined
by Dr. Hunner, the patient being placed in the knee-chest
position and the bowel examined by means of the long
speculum. Examinations for ameba proved negative.
Numerous ulcers were found and the cultures from these
gave a great variety of bacteria but nothing characteristic.
A curetting was done and the debris examined under the
microscope but without showing anything very definite.

Dr. Hunner has drawn here a description of some of the
ulcers as seen at the first examination. They were horse-
shoe-shaped, about 2 cm. from one end to the other and
about 5 or 6 mm. across the narrow portion with a granular-
looking base and very little congestion in the neighborhood.
In his description of the findings it was noted that there was
marked congestion extending up to the sigmoid. The areas
of involvement had very much the appearance of ringworm.

The patient was put to bed, given a milk diet, and silver
nitrate irrigations were administered in varying strength.
After a month of this treatment without improvement the
patient was placed in a knee-chest position, the speculiim
inserted and a piece of iodoform gauze saturated in a 10
per cent ichthyol solution was placed in the bowel and allowed

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

to remain one hour. After the first application she had a
number of stook, but on the following day had them only
after the irrigations. After about six applications she had
no stools except those following applications or irrigations,
and an examination of the rectum showed that the ulcers
had disappeared. On Wednesday last, Dr. Kelly saw her
again and found a few small ulcers, and when I examined
her again to-day I found her condition to be almost as bad
as at first. We shall continue the same treatment and report
results later.

Case 2. — This case presents simply a rather unique way
of dealing with large oozing raw surfaces where the intes-
tines might become adherent and cause trouble. The
patient, a woman aged 60, entered the hospital October 19th
with a large tumor in the left side of the pelvis. The diag-
nosis was made of a possible carcinoma of the left ovary
with adhesion of the structures around it. An incision
was made and a large tumor was found springing from the
left ramus of the pubes. It was not connected in any way
with the ovary or tube and examination proved it to be a
fibroma. We tied off a good many of the blood-vessels
coming from the abdominal walls and tried to cut through
the capsule of the tumor in order to shell it out. In trying
to do this on the right side the scissors entered an open
space, apparently in the capsule, but instead we incised the
bladder for about 8 cm., making a triangular cut. The
tumor was finally enucleated and it left the whole anterior
part of the pelvis a raw surface. This raw surface in front
of the uterus could not be covered with peritoneum, and it
was a question at first how to cover it so as to prevent the
intestines becoming 'adherent. We began on the left side
and sutured the round ligaments up to the anterior abdom-
inal wall and then the uterus was stitched to the wall by
interrupted sutures. The same plan was carried out on the
right side and, after closing the bladder wound, the oozing
area was packed with gauze. In this way the abdominal
cavity was cut ofE entirely from this oozing space in front of
the uterus. The result justified the means, because the
patient recovered without any serious complications.

Demonstration of a New Heinogrlobiiionieter. Dk. Arthur
Dark, I'liiladelpliia.

Through the kindly interest manifested by Professors
Flexner and Hare, I have the honor of presenting a new
instrument for estimating the quantity of hemoglobin in
blood by an improved means. The application of the instru-
ment differs from that operative in the popular instruments
of Yon Fleischl, Gowers and Oliver, by using blood immixed
with artificial serums. The method consists in ascertaining
the percentage of hemoglobin by comparison of the color of
the blood arranged into a thin film of measured thiclmess
with a fixed standard color equally illuminated by trans-
mitted candle-light.

The essential parts of the instrument are an automatic
pipet for collecting the blood, and a graduated color com-
parison to measure the percentage of hemoglobin therein

contained. The pipet for collecting the blood is composed
of an oblong plate of white or opal glass, into the end of
which is ground a depressed surface exactly parallel with its
plane surface, and of measured depth. This depression
forms a very shallow capillary chamber when the transparent
glass is placed over it and the two are clamped tightly to-
gether with a 'pipet-clamp. This space fills automatically by
capillary attraction when either of the three free edges is
touched lightly to the blood drop. AVhen fUled the pipet is
placed upon the stage of the instrument and held in position
by grooves, and is then compared with a color comparison
composed of a semicircle of tinted glass, the periphery of
which represents an increasing shade of color from apex to
base. This is secured to a disc of opal glass which serves
the same purpose as in the pipet, disperses the light and
furnishes a white background against which the color shades
are best appreciated.

The blood and comparison placed horizontally side by
side are viewed through achromatic lenses fitted into the
telescoping camera-tube, and the comparison adjusted by
means of a milled head, which in turn rotates the color prism
until the same corresponds in color with the blood. The
operation is completed by noting the percentage of hemo-
globin indicated.

As the examination only consists of filling the pipet and
comparing the color shade with the comparison, the time
required for an observation is reduced to the minimum of 1 or
2 minutes, which places hemoglobin estimation among the
practical clinical methods.

We will consider the instrument from the aspect of the
scientific hematologist.

By using a stratum of blood the thickness of which is
always constant, we avoid the volumetric character of all
dilution methods. It is evident that if the ends of the
column of blood contained by the pipet are either concave
or convex, or if the outside is soiled, an error must result.

As the blood film is viewed against an illuminated white
background, leucocytosis is imperceptible; only the red color
of the hemoglobin is visible.

With the Fleischl the error due to leukocytosis is consider-
able, as the blood and water mixture is turbid, and does not
compare with the clear tone of the color comparison, making
the readings low, while in leukopenia they are high.

Again, by using undiluted blood we avoid the dilution
color curve; to illustrate, an equal volume or weight of nor-
mal 100 per cent blood and water, instead of reading 50
per cent reads 65 per cent; this discrepancy is the color
curve. In every different sample of blood which is an intra-
vascular dilution, we have a color curve due to different
degrees of hemoglobin concentration; this color curve is
likewise adjusted by keeping an equal concentration of color-
ing matter in the blood film and color comparison ■ e. g.,
blood reading 100 per cent requires greater concentration
of color, hence a thicker stratum of colored glass to give an
equal shade, than a film containing 20 per cent of hemo-
<rlobin.

January, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

We keep the focal distance of all observations uniform by
rising achromatic lenses and a fixed camora-tnbe and obtain
a large field from apertures that cover only 3 per cent of the
comparison disc, against 20 per cent in the Fleischl. We
also have darker shades to compare, an operation less difficult
than with delicate tints.

The instrument can be used in daylight by directing the
line of vision toward a dark surface, as a black coat that does
not reflect light. I frequently use it in the hospital wards
where the brightness of daylight is intensified by the white-
ness of walls and linen.

If the colors do not look alike daylight either direct or
reflected is entering beside the candle flame, the yellow light
of which only in a measure occludes the violet rays of the
solar spectrum.

Five hundred comparative examinations with the instru-
ments of Von Fleischl, Oliver and this instrument show read-
ings always very close to the Oliver.

With the Von Fleischl the results are at variance in low
hemoglobin percentages, in leukemic blood and in blood
showing leukocytosis.

As it is occasionally desirable to keep tlie blood in the
pipet fresh a long time a special pipet is made that protects
the edges of the blood film from exposure to air, except at
two minute points, which are provided for capillarity. This
is not so readily cleansed but is convenient for demonstra-
tion.

In testing the various methods available with luuliluted
blood, viewing the blood film and color comparisons placed
side by side by doubly reflected light (as is used in the
Oliver instrument) was finally abandoned for the much more
satisfactory method of illumination of the blood as the most
perfect means of color analysis.

An attempt was also made to estimate the hemoglobin
through the ear-lobe by illumination with a greater degree
of success than would at first seem possible.

In conclusion, I desire to point to the practicability of tlu'
instrument. The application requires but 1 or 2 minutes,
and no special technical skill to operate. Accuracy is not
sacrificed to celerity; on the contrary the results in successive
trials are constant and more uniform than with dilution
methods.

In testing the instrument with the view to determining
the degree of variations known to exist in colorimetric obser-
vations with other instruments, experiments were made with
clinical patients whose knowledge of the instrument only
extended so far as being able to arrange the colors until the
tone agreed; variations of more than one or two per cent
were very infrequent; with shop girls, accustomed to the
matching of color shades, the readings were still more uni-
form, points that class it as a most valuable instrument of
precision.

I would also call attention to the blood-lancet that accom-
panies the instrument. A bayonet-pointed needle is held by
a simple chuck mechanism to any desired length from the
hard-rubber guard fixed or released bv a turn of the metal

collar. The needle can be removed for sterilization or re-
placed by another needle in case the point is damaged or
corroded.

December 3, 1900.

In the absence of the president, Dr. Jacobs in the chair.
Cirrhosis of the Stoiiiaeli. I)n. MiCkak.

Dr. Osier is unavoidably absent this evening, and as he
would probably prefer to report personally one of the cases
he had intended showing this evening, I will merely present
the specimens from the other case.

The case is supposed to be one of cirrhosis of the stomach,
a rare condition. Unfortunately, Dr. Osier has notes of the
case with him and I can only speak from my own recollec-
tion of them. The patient was about 48 years of age and
his symptoms began about five years ago in a rather sudden
way. It is curious how many patients complain of acute
gastric trouble beginning after a period of overheating Tind
the drinking of cold beer. Such was the history in this
case. The patient gradually lost weight for some time
though he did not suffer from nausea or vomiting. About
a year ago he came to the hospital and his case was diag-
nosed as one of carcinoma of the stomach. He had then
considerable emaciation, moderate ana2mia and a slight ridge
in the abdomen with a sense of resistance but no definite
tumor. There was absence of free hydrochloric acid and
the presence of lactic acid.

About two months ago he consulted Dr. Osier. His his-
tory was practically the same as before with one additional
symptom, namely that in the last year he had been able to
take only a definite small amount of nutriment at one time,
becoming nauseated whenever he exceeded this quantity,
and, that small amount was decreasing constantly. He had
then lost over 100 pounds in weight. The test meal, which
we finally succeeded in getting, was rather unusual in that
it showed 90 per cent of fluid, a total acidity of only 10 and
the total absence of free acids. Upon the long duration of
the case and the above history, Dr. Osier based his diagnosis
of cirrhosis of the stomach.

Dr. Finney, at the operation, found practically an hour-
glass constriction of the stomach. An opening jvas made
in the stomach-wall and at first it was impossible to pass a
finger beyond the stricture. .\ small probe was used, then
a larger one and so on until finally two fingers could be
passed and the stricture was then dilated. The wound was
closed in the usual way but the patient did not do well,
gradually sank and died four days later, apparently from
inanition.

The specimen is here. Sections removed at the time oL'
operation show a great overgrowth of tissue and no sign
of malignant disease or of previous ulcer. Cirrhosis ven-
triculi is a rare condition and the diagnosis is rarely made
during life with any degree of certainty.

Abdominal Tumor coiitalniii^' a Dermoid Cjst. Dr. MricHi:i,i,.

The case was one of a young man, .34 years of age, who
gave a history of the presence of colicky pains in the abdo-

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

men during the past ten years. During the past five years
these pains have increased in severity. Tliree years ago he
first noticed a tumor about three or four inches just below the
umbilicus, and under the impression that it was a floating
kidney, an exploratory incision was made to-day, and a der-
moid cyst in the mesentery of the ilium was found. (A
fuller account will be published later.)

Discussion.

Dr. Futchee. — In regard to the question of diagnosis of
this ease, the possibility of its being other than a displaced
kidney was entertained. Dr. Osier, as well as Dr. Finney,
spoke of the possibility of its being a mesenteric tumor or a
tumor in connection with the bowel but it seemed to conform
more to the general character of a floating kidney, although
its shape was not exactly that of a normal kidney. Personally.
I thought it was a displaced kidnej', but Dr. Osier was rather
non-committal. Dr. Young made a cystoscopie examination
and found the flow of urine from the two ureters to be
normal. This should have impressed us more strongly than
it did as to the probability of its not being a kidney tumor.

Dr. Bloodgood. — There have been three other dermoids
on the surgical side during the last ten years, although very
few tumors of the mesentery itself. Two of the dermoids
were in men of about 30 years of age and the patients had
not been aware of their existence for any length of time.
Both were opened and drained. Both were behind the peri-
toneum and the autopsy on one proved that the tumor could
not have been removed. The third cyst was, I think, in
practically the same location as in the case reported by Dr.
Mitchell, but it was adherent to the bladder and was asso-
ciated with attacks of hematuria. It was demonstrated later
that a carcinomatous growth had been engrafted upon the
cyst.

Two Cases of Acute Pancreatitis. Dh. Bloodoood.

The first case has been reported by Dr. Thayer and the
second is a recent one that Dr. Mitchell and I saw together
with Dr. Futcher. The disease is so rare that I think the
few of us fortunate enough to see it should be good enough
to bring it before the majority. The diagnosis is not often
made, but I believe an early diagnosis followed by operation
would in the majority of instances be followed by recovery.
In the last ten years we have had some 12,000 surgical
admissions to this hospital and probably as many more on
the medical side, but we have only seen in all that number
three cases of pancreatitis; one hemorrhagic and two sup-
purative. As I had had the good fortune to see the first
case the diagnosis of the second was not difficult.

The patient was a physician, 47 years of age, whose only
previous illness consisted in symptoms of indigestion with
pain after eating associated with slight distension and rarely
nausea and vomiting. Seven months previous to his last
attack he bad with one of these spells a condition of jaun-
dice which lasted three weeks. The onset of the last attack,
18 days before coming to the hospital, was sudden and asso-

ciated with nausea, vomiting and intense cramp-like pains
all over the abdomen. After five days of this, his abdomen
was slightly distended but there was no area of tenderness.
The vomiting was worse during the first 24 hours and only
present at intervals after that. On the third day his tem-
perature was high, for the first time reaching 101.5°. On
the seventh day his physician noticed a mass in the right
lumbar region but he does not give the location very defi-
nitely. He then began to have irregular fevers and chills
and throughout the entire attack the abdominal pains were
present but not very marked except during the first day.
There was no jaundice.

The tumor was visible only to the right but was palpable
some distance to the left of the median line. There was a
leukocytosis of 19,300. The patient remained under obser-
vation for three days with very little change in his condition
except that he was growing weaker and slightly delirious.
When I saw him he was in a toxic condition and looked very
ill. The surface over the tumor was very irregular, like
that of the omentum around an acute appendicitis. The
mass was large and immovable at that time and all around
the tumor a tympanitic note was obtained on percussion.
The position of the tumor corresponded with that of the first
and was different from that of appendicitis or other tumors
in the abdomen.

At the operation, performed under cocaine, there was
found to be a great deal of fat and the omentum was studded
with areas of fat-necrosis. The tumor was adherent to the
parietal peritoneum, and a tendency to bleed was noticed
but there was no hemorrhagic area. The mass under the
omentum was hard and everything about it bled easily when
separated. For that reason the knife was not used but the
fingers were employed to separate the parts. When pus
was found it was first yellowish and then of a deeper brown
color like chocolate. There were at least 2.50 cc. and it
seemed to come from numerous pockets. The man died
within 12 hours after the operation, which seemed to have
no particular effect on his condition.

Discussion.

Dr. Opie. — In Dr. Bloodgood's case the autopsy showed
an abscess occupying the site of the lesser peritoneal cav-
ity. The incision made at the operation passed through the
greater omentum between the stomach and transverse colon
and the drainage tube entered a large cavity lined with
necrotic fat. The tumor mass felt during life was not the
pancreas but spongy brownish-red material which lay in
front of it and on examination proved to be changed blood.
The orifices of the common duct and pancreatic duct were
separated by a thin membrane; a gall-stone was lodged in
the common duct near its orifice in contact with this mem-
brane and therefore in such position that it could compress
the pancreatic duct. The pancreas was the seat of beginning
chronic interstitial inflammation and there was evidence
that hemorrhage had occurred into and about it. In thirty-
one reported cases I found that acute lesions of the pancreas

Januakt, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

have been associated with the presenoc of gall-stones, and in
seven of these cases a stone ocenpied a position similar to
that just described. In four of these seven cases the STOip-
toms were very acute, and death occurred within 48 hours:
the autopsies showed infiltration of the pancreas with blood.
Tt is difficult to say whether the condition was a simple
hemorrhage or a hemorrhagic infiamniation. It seems prob-
able that in this case the stone lodged in the common duct
occluded the paiu-reatic duct. As the result of subsequent
changes hemorrhage occurred into and about the gland.
The patient surxived the primary lesions and thus gave
o]iportunity for secondary infection resulting in a peri-
pancreatic abscess.

Tuberculosis of the Aorta. Mii. Longcope.

The patient was a colored child admitted to the Johns
Hopkins Hospital November 9, 1899. and a diagnosis of
tuberculosis of the hip was made. On examination the heart
and lungs were found normal. The cervical lymph-glands
were palpable. On November 11th an incision of the sub-

r?;

►'F

Fig. 1. — Small tubercles at the margin of the necrotio mass. The
section is from the lower end of intima.

gluteal abscess and arthrotomy were done. TJie wound
healed well and the child remained in good condition until
JanuaiT 10, 1900, two months after the operation, when a
cough was noticed. A few days later on, January '20th, the
child's temperature, which had been practically normal, rose
to 103°, and an examination of the lungs showed patches
of consolidation in the left apex and both lower lobes. From
this time the patient's temperature was more or less elevated
and occasionally reached 10-1°. The patient grew steadily
weaker and died on ^Farch -3, 1900, almost four months after
the operation.

The anatomical diagnosis made at the autopsy reads —
Tuieratlosis of the hip: abscess formation in the muscles
anterior to the aceluhulvm; chronic tuberculosis of the right

lung: niiliiiri/ iuhemilosis of the lungs, liver and spleen ;'actiie
splenic lunior: lii/jjcr/ihisia of tlic h/iii ptiatlc glands and hjin-
pliatic tissue in ilie intestines: mural Ihromhus of the aorta.

The chronic tuberculosis of the right lung consisted in a
caseous patch about 5 cm. in diameter at the apex of that
lung. Although the kidneys showed no distinct tubercles
macroscopically, still on microscopic examination aggrega-
tions of epithelioid and lymphoid cells were found which
strongly suggested tubercle. The thrombus was situated on
the posterior wall of the lower abdominal aorta, and con-
sisted of a ])olyp(iid projection about 3 em. in length, bent
downwards and closely hugging the wall of the aorta. At
its lower extremity a fresh red thrombus mass was attached.

A section of the lesion in the aorta shows that the nodule
is composed of a mass of necrotic granular material, con-
taining no cell elements. It is surrounded, except at its
lower extremity, by intimal tissue, and presents much the
ai]pearance of an ordinary atheromatous placque. On close
examination, however, the lining intima is found to contain
epithelioid and lymphoid cells which at its lower extremity
arrange themselves into two definite tubercles containing
giant cells (Fig. 1). About the periphery of the necrotic
granular material and beneath the intimal border are seen
masses of fibrin. Near the intima the fibrin is continuous
with radially placed cells of an epithelioid type. The ne-
crotic mass itself contains great numbers of tubercle bacilli,
which stain with carbol fuchsin, and are not decolorized after
treatment with 10 per cent nitric acid for half an hour.
These bacilli also stain well in alkaline methylene blue.
The entire lesion of the intima, then, must be considered a
chronic tuberculosis with marked caseation.

The media, on the other hand, presents a dilfercnt picture.
Directly beneath the lesion in the intima, masses of lymphoid
and epithelioid cells with a few giant cells are seen in the
media. There is no definite arrangement of these cells sug-
gestive of tubercle. At one point the growth in the media
and the caseous mass in the intima are separated only by a
few elastic fibres, but in greater part the lesion is confined
to the middle portion of the media. Numerous blood-vessels
are seen running through the diseased portion. VVeigert's
elastic fibre stain shows that the elastica has been greatly
damaged. The tuberculous process has broken the elastic
fibres into small pieces which appear as short curled threads.
The lesion occu]iying the mid portion of the media pushes
outward, and at its margins widely separates the elastic
fibres next the adventitia. These fibres are often broken
and their ends shar])ly bent outward. In no place does the
growth in the media extend into the adventitia, and, except
for increased vascularity and slight thickening, this coat
appears practically normal.

Few cases of tuberculous aortitis have been reported;
whereas tuberculosis of the veins and smaller arteries seems
to be of comparatively frequent occurrence. In 1883,
Weigert, in an article on tuberculosis of tlie veins in A^ir-
chow's Archives, descrilx's two cases of miliary tuberculosis
of the aorta which AFarchand and Ilubcr showed him. In

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 118.

the same volume of the Archives Schuchardt meutious a case
of miliary tuberculosis of the abdominal and thoracic aorta
occurring in a case of general miliary tuberculosis. Eight
subsequent cases have been reported in Germany and France
by Dittrich, Hanot, Kamen, Hanot and Levy, Hauau and
Sigg, Buttermilch and Benda; and three eases in America,
one by Dr. Flexner, a second by Dr. Blumer, and Dr. Welch,
in his article on Thrombosis and Eiubolism, mentions a third
case shown to him by Dr. Gaylord.

These fourteen cases can be divided into two groups: those
in which there is a primary tuberculosis of the intima caused
by a direct deposition of the bacilli from the blood stream,
upon the endothelium of the aorta; and those in which the
adventitia is the seat of primary invasion with an extension
of the process into the media and intima. Ten of the four-
teen cases belong to the first group, and in this grouj) also
the present case should be included. In all the cases of this
group of primary infection of the intima, except that re-
ported by Stroebe, the tubercles were either miliary or ex-
ceedingly fresh. In Stroebe's case, however, a caseous polyp
surrounded by epithelioid cells was found projecting from
tlie intima of the ascending aorta. This polyp was capped
by a thrombus mass. The present case closely resembles
that of Stroebe.

Of the four cases of group II, the primary involvement
of the adventitia occurred in the following manner: Twice.
■(". e. in the cases of Dittrich and Kamen. a caseous lymph
ghmd was I'duiid adherent to the adventitial wall of the
aorta, and the tulierculous process could be traced directly
from this focus into the media and intima. Ilaiiau and Sigg
describe a jiortion of a tuberculous lung adhering to the
arch of the aorta. A small aneurysm of the aortic wail
projected into a tuberculous cavity of the lung. The
aneurysm was filled with a thrombus mass. Tubercle bacilli
were found in the tlironilms and artery wall. In the fourth
case of tliis grou]) Buttermilch traced the aortic tuberculosis
from a chronic tuberodDUs focus in tlu' thoracic vertebnv.
The aorta and vertebra^ were firmly adherent, and small
caseous abscesses were found in the adhesions.

In connection with the present case it is interesting to
note Benda's views concerning the ])art played by tuber-
culosis of the blood-vessels in general miliary tuberculosis
following operation or injury of tuberculous joints and bones.
In three of such cases he finds tul)erculosis of the blood-
vessels, and he believes tliat during the operation or injury
a few bacilli make tlieir way into the circulation and lodge
upon the intima of some blood-vessel, thus forming as it
were a tuberculous metastasis. At this time there is no
general invasion of the bacilli. In the intima of the vessel
a tubercle develops, becomes caseous and finally ruptures,
liberating great numbers of tubercle bacilli into the circu-
lating blood. These bacilli are distributed throughout the
body and arc the direct cause of the general miliary tuber-
culosis.

Since in the present case the aortic tuberculosis is the
only chronic process except the focus in the riglit luno-, it

is not impossible that the general miliary tuberculosis may
have been directly caused by the rupture of the caseous
tubercle of the intima.

LiTEEATUHE.

Benda: Berl. Klin. Wochenschrift, 1899, Nos. 26, 27 and
29; Berl. Klin. Wochenschrift, 1899, Nov. 19, p. 120.

Blumer: American J. of lied. Sciences, Jan., 1899, p. 19.

Buttermilch: Inaug. Diss., Berlin, 1898.

Dittrich: Zeitschrift f. Heilknnde., Brag., Bd. IX, 1888,
p. 97.

Flexner: ,1. H. H. Bull., Aug., 1891, p. 120.

Hanot: Sem. Med., 1895, p. 281.

Hanot and Levy: Arch. d. med. exper. et d'anat. path.
Par. 189G, VIII, p. 784.

Hanau and Sigg: Mit. aus. klin. und Med. Instit. der
Schweitz. 4 Eeihe. Bd. IV, 1896, p. 173.

Kamen: Beit. /,. path. anat. u. z. allg. Path., Jena, Bd. 17,
189.5, p. 416.

Schuchardt: Virchow's Archiv, 1882, Bd. 88, p. 46.

Stroebe: Centrblt. f. allg. Path. u. path. Anat., Jena,
1897, p. 866.

Weigert: Virchow's Archiv, 1882, Bd. 88, p. 360.

Welch: Thrombosis and Embolism, Allbutt's System of
Medicine, 1899.

NOTES AND IVEWS.

Dr. dohn S. Hillings, Jr., Assistant Ecsident Physician at
the Hospital during 1892, "93 and "94, resides at 32 East
53rd St., New York City. He is Assistant Director of the
Bacteriological Laboratory of the Department of Health,
having resigned his position of Instructor in Clinical Micro-
scopy in the University and Bellevue Hospital Medical
School.

Dr. C. N. B. Camac, Assistant Eesident Physician at the
Hospital during 1896, '97 and '98, resides at 108 East 65th
St., New York City. He is Visiting Physician to the City
Hospital, and Insti-uctor in Clinical Pathology at the Cornell
Medical School.

Dr. E. P. Carter, Assistant Eesident Physician at the Hos-
pital in 1894 and '95, resides at 8 Hayward St., Cleveland, 0.
He is Lecturer on Medical Jurisprudence in the Western
Eeserve University Medical School, a member of the staff of
the City Hospital, and an Assistant in the Out-Patient De-
lia rtment of the Lakeside Hospital.

Dr. Edmund D. Clark, Assistant Eesident Surgeon at the
Hospital in 1895, resides at Indianapolis, Ind. In 1896 he
was appointed Demonstrator of Histology in the Medical
College of Indiana: in 1897, Adjunct Professor of Physiology
and Surgical Pathology; in 1898, Consulting Surgeon of the
City Hospital, and in- 1899, Instructor in General Surgery
at the Protestant Deaconess Hospital.

Dr. George Edward Clark, Assistant Eesident Surgeon at
the Hospital in 1889 and 1890, resides at Skaneateles, N. Y.

Dr. John G. Clark, Eesident Gynecologist at the Hospital
in 1895 and "96, has been appointed Consulting Gynecolo-

January, 19iU.J

JOHNS HOPKINS HOSPITAL BULLETIN.

gist to the Woman's Hospital, Philadelphia. He resides at
218 South 1.5th St.

Dr. Malvern B. Clopton, Assistant Eesident Surgeon at
the Hospital in ]S9S, resides at 3732 Olive St., St. Louis,
Mo., and is connected with the Medical School of the Wash-
ington University.

Dr. Theo. Coleman, Assistant Eesident Surgeon at the
Hospital in 1895 and '96, who now resides at 569 Spadina
Ave., Toronto, Ont., has been appointed Head Surgeon and
Physician to the Canadian Copper Companj', at Copper
Cliff.

Dr. J. Colton Deal, Assistant Eesident Obstetrician at the
Hospital in 1898, resides at 5301 Haverford Ave., Phila-
delphia. He is Pathologist to the Gynecological Department
of the Polyclinic Hospital.

Dr. George W. Dobbin, Assistant Eesident Obstetrician
at the Hospital from 1894 to '97 and Eesident Obstetrician
from 1897 to '99, has been appointed Professor of Obstetrics
in the College of Phj'sicians and Surgeons of Baltimore.
He resides at 923 N. Charles St., Baltimore.

Dr. W. W. Farr, Assistant Eesident Gynecologist at the
Hospital in 1890 and '91, resides at 5728 Greene St., Phila-
delphia, Pa.

Dr. McPheeters Glasgow, Assistant Eesident Gynecolo-
gist at the Hospital in 1896 and '97, resides at 151 N. Spruce
St., Nashville, Tenn., and is connected with the Vanderbilt
Medical School.

Dr. Francis E. Hagner, Assistant Eesident Surgeon at
the Hospital in 1896, resides at 1717 N St., Washington,
D. C. He has charge of the Surgical Dispensary at the
Garfield Hospital, and is Instructor in Bacteriology at the
Columbian University Medical School.

Dr. Hunter Eobb, Eesident Gynecologist at the Hospital
from 1889 to 1894, resides at 1342 Euclid Avenue, Cleve-
land, 0. He is Professor of Gynecology at the Western
Eeserve University, and G_ynecologist-in-Chief to the Lake-
side Hospital.

Dr. Chauncey P. Smith, Assistant Eesident Surgeon at
the Hospital in 1893 and '94, resides at 90 N". Pearl St.,
Buffalo, N. Y.

NOTES ON NEW BOOKS.

■Cancer of the Stomaoli: A Clinical Study. By William Osler.
M. D., and Thomas McCeae, if. B. (Tor.), of the Johns Hop-
kins Hospital, Baltimore. With illustrations. {Philadelpliia :
F. Blakistoii's Son d Co., 1900).

The prevalence of cancer of the stomach, and the value to the
physician of a thoroug'h knowledge of the clinical features of
the disease, as well as the importance to the patient of its early
recognition, makes this admirable monograph a welcome acqui-
sition to our literature on the subject.

The monograph contains 157 pages with several illustrations
in the text. It is essentially a critical study of 150 cases of
primary cancer of the stomach admitted to the Johns Hopkins
Hospital from its opening, May 5, 1S89, until March 31, 1898.
Of these, 2 were instances of multiple primar3' cancer. During
the same period 3 cases of secondary cancer of the stomach

came under observation, and these are considered separately.
The literature has been carefully e.xamined and much additional
information thus added.

The authors believe there is evidence that cancer in general is
on the increase. They hold, however, that there is not sufficient
proof at hand to warrant the same conclusion concerning
cancer of the stomach. The general etiology of the disease is
then taken up. The ratio of the disease in males and females
was 5 to 1. The greatest number of cases occurred in the fifth
decade. The white and colored race are apparently about
equally liable. The ratio of the disease in the two races was
respectively 6.9 to 1. The ratio of admissions is 6 to 1. In only
6 cases was there a family history of cancer. There was a
history of ulcer of the stomach in 4 cases. Trauma seemed to
bear a causal relationship to the onset of the disease in only one
instance.

An interesting chapter is devoted to cancer of the stomach in
the young. The writers give 30 years as the convenient dividing
line below which cancer of the stomach may be considered as
occurring in the young. They have collected from the literature
6 authentic cases in the first decade and 13 in the second. The
number of cases which are reported as occurring in the third
decade is much larger and forms an interesting group from the
standpoint of diagnosis. All their cases below 30 were in the third
decade, the youngest patient being 22 years of age. There were
6 cases, or 4 per cent of the total, in this decade, and they con-
sider this number unusually large. An important feature of the
disease in the young is its rapid progress.

General instructive chapters are devoted to an analysis of the
symptoms present in the 150 cases. An interesting feature was
the surprisingly large number of patients who gave a history of
an acute onset. There were 37 cases in which the onset could be
termed sudden. The three most constant symptoms were pain,
vomiting and tumor. Pain occurred in 130 cases, or 86. G per
cent.; vomiting in 128 cases, or 85.3 per cent.; tumor in 115 cases,
or 76.6 per cent. In 87 cases in which stomach contents were
obtained for examination, there was an absence of free hydro-
chloric acid in SO, or 92 per cent. There were seven cases in
which free hydrochloric acid was found. In the series, lactic
acid was examined for in 73 cases and was found present in 55,
giving 75.3 per cent. The writers consider that UfEelmann's test
for lactic acid is satisfactory, laying stress on the fact that an
ethereal extract should be used in making the test.

Certain associated and secondary symptoms are then taken
up. Perforation into the peritoneal cavity or adjacent portions
of the intestinal tract occurred in 6 cases. In 2 cases there were
secondary metastases at the umbilicus. Jaundice was present
in 6 and ascites in 8 cases. Thrombosis of the left femoral vein
occurred in 2 cases. Thrombi were found post mortem in 3
cases. There was one remarkable case in which thrombosis of
fourteen or fifteen veins was found.

.Some of the most interesting chapters are devoted to tlie study
of the different features associated with the site, shape, struc-
ture and character of the tumor, which was made out in 115
cases. The importance of inspection of the abdomen is em-
phasized. In 42 cases the stomach was dilated, the dilatation
in each case being visible to the naked eye. The atrophic form
of carcinoma ventriculi was present in 12 cases, and was recog-
nized in 6 during life.

A chapter is devoted to the blood in cancer of the stomach.
It is rather disappointing to find that in the cases in which the
blood was examined for a digestion leucocytosis, the absence
of such a leucoc3'tosls was not by any means a constant feature.
In 22 cases thus examined it was present in 10 and absent in 12.
They are inclined to the opinion that little reliance can be
placed on the digestion leucocytosis from a diagnostic stand-
point.

JOHNS HOPKINS HOSPITAL BULLETIN.

[Xo. 118.

The disease was latent in 8 cases and was unsuspected during
life. Autopsies were obtained in 46 cases. The following figures
give the frequency of involvement of the various regions of the
stomach: Pyloric region, 24; general involvement. 6; lesser curva-
ture, 5; greater curvature, 3; cardia, .3; posterior wall, 3;
fundus, 1.

The monograph concludes with the therapeutic management
of the disease. The medical treatment is palliative and is in-
tended for those cases which are beyond surgical interference.
The surgical treatment is radical or palliative. The writers
state that an exploratory operation should be more frequently
advised. They hold that results from the radical procedure in
recent years are encouraging, and believe that the future should
show a marked increase in the percentage of recoveries. In this
connection thej' emphasize the great importance of an early
diagnosis of the disease. The palliative surgical measures are
undertaken to overcome the eifects from stenosis of one or
other of the cardiac orifices.

The monograph is concise and to the point. The statistics are
of special value, as the cases were all observed under the same
conditions. Careful studies of this kind do much towards in-
creasing our knowledge of the diseases of particular organs.

A Text-book of the Practice of Medicine. By James M. Anders,
M. D., of Philadelphia, Fourth edition. (Philadelphia: W. B.
Saunders & Co., 1900.) . .^ ' f

Only a year has passed since the appearance of the third edi-
tion of this work, yet Dr. Anders has made many additions and
recent literature has been frequently quoted in the present one.
There are some things we miss, however. Little is said of the
occurrence of typhoid bacilli in the urine of typhoid-fever
patients. More emphasis might have been laid on the import-
ance of thorough disinfection of the urine. Probably more
eases of direct infection of typhoid have been due to the urine
than to the faeces. In discussing the treatment of pneumonia.
Dr. Anders advises the giving of large doses of strychnine hypo-
dermically, as much as one-fifteenth of a grain everj' two or
three hours. The administration of digitalis is only advised in
the event of great cardiac weakness. The experience of this
hospital has been that digitalis is of more service in these cases
than the tincture of digitalis.

In reviewing a text-book of medicine there are certain sections
that are probably most often first referred to as an index of the
author's views. Of these, possibh' that on appendicitis comes first.
Dr. Anders here speaks with no uncertain voice. He considers
that the phj-sician and surgeon " should stand guard together
from the moment the case is diagnosticated or appendicitis is
strongly suspected." The same remark might well be applied
to many of the border-line conditions between medicine and
surgery. He speaks for the vigorous use of salines in cases
where there is peritonitis with pus-formation and operation can-
not be performed.

The author still clings to elaborate tables of differential diag-
nosis throughout. The sections on diagnosis are good, but
probablj' the best department is that of treatment. This is
consistently good and a valuable feature of the work. There are
few text-books in which this is better handled.

Atlas and Epitome of Special Pathologic Histology. Authorized
translation from the German, by Docent Dr. Hermann Durck.
Edited by Ludwig Hectorn, M. D. With 62 colored plates.
(Phihidelphia: W. B. Saunders, 925 Walnut St., 1900.)

The first volume of this work deals with the pathological his-
tology of the circulatory organs, respiratory organs and gastro-
intestinal tract. Two more volumes are to follow. The illus-

trations, which naturally occupy a considerable space in the
atlas, are well printed on heavy paper, but the colors are dis-
appointing. Several of the figxires, however, are very good. The
text is made up of short accounts of the various pathological
processes. These descriptions, of course, do not pretend to be
exhaustive, but the beginner in the study of pathology will no
doubt find them very useful in connection with laboratory work.
The book is not an attractive one at first glance, but its concise
text and numerous illustrations make it a useful addition to a
laboratory.

BOOKS RECEIVED.

Transacti-cms of the OpMhalmologic and. Otolaryngologic Association,
at its Fifth Annual Session, held in St. Louis, Mo., April 5,
6 and 7, 1900.

Archives of tJie Roentgen Ray. Edited by Thomas Moore, F. R. C. S.,
and Ernest Payne, M. A. (Cantab). Vol. 5, No. 1, August,
1900. 4to. Kebman, Limited, London. Queen & Co., Phila-
delphia.

Cancer of the Stomach. A Clinical Study. By William Osier, M. D.,
and Thomas McCrae, M. B. (Tor.). With illustrations. 1900.
8vo. 157 pages. P. Blakiston's .Son & Co., Philadelphia.

Transactions of the Texas State Medical Association. Thirty-second
annual session, held at Waco, Texas, April 24 to 27, 1900.
8vo. 400 pages. Austin, Texas.

Tuberculosis: Its Nature, Prevention and Treatment. With spe-
cial reference to the Open-air Treatment of Phthisis. By
Alfred Hillier, B. A., M. D., C. M. With thirty-one illustra-
tions and three colored plates. 1900. 12mo. 12 -f- 243 pages.
Cassell & Co., Limited, London, Paris, New York and Mel-
bourne.

Diseases of the Gall-bladder and Bile-ducts, including Gall-stones.
Bj' A. W. Mayo Eobson, F. E. C. S. Assisted by Farquhar
Macrae, M. B., CM. (Glas.). Second edition. 1900. 8vo.
313 pages. Bailliere, Tindall & Cox, London.

Transactions of the Indiana State Medical Society, 1900. Fifty-first
annual session, held at Anderson, Indiana, May 24 and 25,
1900. 8vo. 478 pages. Indianapolis.

Essentials of Histology. By Louis Leroy, B. S., M. D. Arranged
with Questions following each chapter. 72 illustrations.
(Saunders' Question-Compends, No. 25). 1900. 12mo. 231
pages. W. B. Saunders & Co., Philadelphia and Loudon.

Index Catalogue of the Library of the Surgeon-General's Offlw, United
States Army. Authors and Subjects. Second Series, Vol. V.
Enamel-Fyuner. 1900. 4to. 1127 pages. Government Print-
ing Oilice, Washington.

Guy's Hospital Reports. Edited by E. C. Perry, M. A., M. D., and
W. H. A. Jacobson, M. Ch. Vol. LIV, being Vol. XXXIX of
the third series. 1900. -8vo. xli -|- 341 pages. J. & A.
Churchill, London.

Modern Medicine. By Julius L. Salinger, M. D., and Frederick J.
Kalteyer, M. D. Illustrated. 1900. Svo. 801 pages. W. B.
Saunders, Philadelphia and London.

Anomalies of Refraction and of the Muscles of the Eye. By Flavel
B. Tiffany, A. M., M. D. Fourth edition. 1900. Svo. 307
pages. Hudson-Kimberlj- Publishing Co., Kansas City, Mo.

Sexual Debility in Man. By Frederic E. Sturgis, M. D. 1900.
Svo. 432 pages. E. B. Treat & Co., New York.

Transactions of the Association of American Physicians. Fifteenth
session, held at Washington, D. C, May 1, 2 and 3, 1900. Vol.
XV. Svo. xxi -\- 542 pages. Printed for the Association,
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BULLETIN

THE JOHNS HOPKINS HOSPITAL.

Vol. Xll.-No. 119.]

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CONTENTS.

Preliminary Note of a Case of Infection with Balautidium Coli
(Stein). By Richard P. Strong, M. D., and W. E. Musgrave,
M. D., 31

Hyperextension as an Essential in the Correction of the Deformity
of Pott's Disease, with the Presentation of Original Methods.
By R. TuNSTALL Taylor, B. A., M.D., . . '.' 33

Two Examples of Bence Jones' Albumosuria Associated with

Multiple Myeloma. By Louis P. Hamburger, M. D., . . . 38

Report of a Case of Fulminating Hemorrhagic Infection due to an
Organism of the Bacillus Mucosus Capsulatus Group. By
George BLnMEE, M. D., and Arthur T. Laird, M. D., ... 45

Introductory Note to Drs. Durham and Myers's Report. By Wil-
liam H. Welch, M. D

Abstract of Interim Report on Yellow Fever by the Yellow Fever
Commission of the Liverpool School of Tropical Medicine. By
Herbert E. Durham, and the late Walter Myers, .... 48

Summaries or Titles of Papers by Members of tlie Hospital and

Medical School Stall' Appearing Elsewhere than in the Bulletin, 4i)

Notes on New Books, 50

PRELIMINARY NOTE OF A CASE OF INFECTION WITH BALANTIDIUM COLI (STEIN).

By' Eichakd p. Strong, M. D.,
Assistant Surgeon, U. S. A., Director of the Army Pathological Lahoralorij, Manila.

AND

W. E. Musgrave, M. D.,
Hospital Steward, U. S. A., Resident Pathologist to the First lieserve Hospital.

(From the Army Falholoijkal Laboratory, Manila, P. I.)

Balantidium coli (Steiu), (Paramecium coli — Malmsten)
was probably first observed by Leeuwenhoek. In a diarrhoea
of considerable duration, he examined his own stools and rec-
ognized in them small motile animals, which, he stated, were
about the size of red blood-corpuscles, and moved by means
of small " f ussartig " formations.

Lenekart intimated that the size of the parasite, as given
by Leeuwenhoek, probably rested on a guess, as the latter
author was not able to notice any flagella with the micro-
scope of his time.

Malmsten,' in 1857, in Stockholm, first described the par-

' Malmsten: Infusorien als Intestinal-Thiere beim Menschen.
Virchow's Archiv, Bd. sii, p. 302.

asite in a patient who, for two years following a case of
cholera, had suffered at first from digestive troubles and
later from a painful diarrhoea. On examination of the pa-
tient he found, about an inch above the anus, a small wound,
which excreted a thin, bloody pus. A great number of the
parasites were constantly found in this discharge and also
in the intestinal mucus and freces. The condition of the
patient improved considerably with the decrease in the
number of the parasites. Lowen classified these parasites as
belonging to the genus Paramecium.

In a second case Malmsten found the parasite in the bloody
pus-like excretions of a woman suffering from a severe intes-
tinal catal-rh. The woman died. At necropsy, he states,
the parasites were found on the healthy mucous membrane

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

of the cfEcum and in the vermiform apipendix. They were,
however^ missing entirely in the small intestine. In small
numbers they were found in the ulcers of the large intestine.

In 1862 Stein proposed the name Balantidinm eoli for the
parasite.

In 1891 Mitter ' was able to collect from the literature
twenty-eight cases of infection with this parasite. Since
this date, De la Chappelle ' (1896), has reported two other
eases in man. The article of this latter author is not at
hand.

Henschen especially emphasizes the pathological import-
ance of this parasite, but other authors are inclined to the
belief that its presence should only be considered as an
accidental, unimportant complication. The latter view is
the one which is generally expressed in our recent text-books
regarding this parasite. Thus Opic ' (1900), in his article
on Protozoa, concludes that Balantidinm coli is apparently
an accidental parasite which finds favorable conditions for
growth in the diseased intestine and that it is improbable
that the organism is the etiological factor in the production
of the diarrhoea with which it is associated.

We wish to contribute another case to the literatiire of
infection with this parasite.

The patient observed by us had lived in northern New
England and came to the Philippine Islands in December,
1899. There was no history of previous diarrhoea. He
stated that he had been perfectly well until April, 1900,
when he began to have diarrhoea which continually grew
worse. He entered the hospital here on June 9. From this
date up to the time of his death, August 11, he had con-
tinuous, uncheckable, severe diarrhoea.

He became extremely emaciated before his death. Dur-
ing life, the blood-examination showed a relative increase in
the number of the cosinophiles. The stools showed large
numbers of flagellate infusoria measuring from 70// to
110/ilong by 60 to 72 « broad. The periphery is covered
with fine actively motile cilia. At the anterior end is a
funnel-shaped entrance which is surrounded by cilia and
when the parasite is moving, gives the appearance of a

'Mitter: Beitrag zur Kenntuiss des Balnnt. coli. Inaiig. Diss., Kiel
1801.

^ De la Chapelle : Finska lak.-sallsk. liandl., Ilelsiugfors, 1S90; xxxviii,
1041.

■• Opie : Twentieth Century Practice of Medicine, vol. six, 1900.

paddle-wheel revolving. An ectosarc and endosarc may
be distinguished, and the parasite possesses the power to
change its shape and may appear quite round. The en-
dosarc contains a large somewhat kidney-shaped nucleus and
two contractile vacuoles. The surface is lightly striated
longitudinally. In the posterior end is an anus from which
particles were observed, at times, to pass. The anterior end
is more pointed than the posterior and more tapering. For
some days before death, each drop of the patient's fasces,
placed beneath a cover-glass, contained between 100 and
200 of these infusoria. The stools contained no other para-
sites, but mucus, blood and epithelial cells were present.

At necropsy, in the lower portion of the jejunum and
ileum the mucosa was reddened and contained considerable
mucus. In the large intestine the mucosa throughout was
covered with bloody mucus which was easily washed off;
beneath this layer the mucosa itself was very much red-
dened. There were a number of shallow ulcerations pres-
ent in the mucosa whose edges were not undermined; their
bases and margins had a blackish pigmented appearance.

Agar plate cultures from the heart, spleen, liver and kid-
neys were negative for organisms.

Sections of the large intestine stained in hematoxylin
and eosin show Balantidinm coli all through the mucosa
and passing through the mnscularis and submueosa; some
of the sections show the parasites lying along the inter-
muscvdar septa of connective tissue and penetrating for a
short distance between the muscular layers. There is an
extensive eosinophilia in the mucosa, muscularis mucosa,
submueosa and lymph follicles. The process seems more
marked in the submueosa. The mucosa shows areas of
necrosis and of hiemorrhage, with cellular infiltrations and
desquamation of cells. In the submueosa there are also in-
filtrations of round cells; the vessels are injected and often
about the veins which contain the parasites small hsemor-
rhages have occurred. The lymph follicles are swollen.
The liver shows small areas composed of round cells.

We cannot regard this parasite as a harmless one, for we
could not explain the persistent diarrhoea of our patient
without regarding it as the exciting cause, nor were we, from
the lesions found at necropsy, enabled to explain his death
in another way. A complete report of this case will appear
shortly.
October 4, 1900.

HYPEREXTENSION AS AN ESSENTIAL IN THE CORRECTION OF THE DEFORMITY OF POTT'S
DISEASE, WITH THE PRESENTATION OF ORIGINAL METHODS/

By p. Tunstall Taylor, B. A., M. D.,
Surgeon to the Hospital for Crippled Children, Baltimore; Fellow of the American Orthopedic Association, etc.

Any successful treatment of tuljcn-ular spondylitis must
be based on a careful consideration of the anatomical, patho-

' Read, in part, at the Fourteenth Annual Meeting of the American
Orthopedic Association, on May 13, 1900, Washington, D. C.

logical and mechanical problems involved, and any method
determined on must stand the test of clinical experience
before acceptance.

Let us first consider briefly some of the chief anatomical
features of the spine from the standpoint of the mechanics

Februaet, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

in the causation and in the treatment of this tubercular
osteitis of the vertebrje.

The vertebral column as a whole consists of four curves
when viewed laterally — a convexity forward in the cervical
region, a convexity backward in the dorsal region, a con-
vexity again forward in the lumbar region and backward
in the sacral.

The three first-mentioned curves, with which we are only
concerned, are subject to variations dependent on whether
llie individual is standing or sitting, and also whether the
observation is made on rising in the morning or late in the
evening, being in the latter cases more marked.

It has been shown by Brackett ' that recumbency in a
prone position lessens these curves, and supine recumbency
has been used from time immenunial as an efficient means
of treating spinal curvatures.

Suspension by the liead and hands also renders these phys-
iological curves, if we may so designate them, less appre-
ciable. Le Vacher " demonstrated this in 1768 in his
" L'arbor suspendens " attached to a corset.

The " jury-mast," for which Lee ' gives the credit to J. K.
Mitchell in 182t), and Lee's own " self-suspension spinal
swing," devised in 1866, confirmed this observation. We
know now, however, that these physiological curves are
chiefly lessened by suspension and not the curves due to
tubercular disease as the earlier observers thought.

In the erect posture the spine must bear the superincum-
bent weight of the head, and by means of the ribs and
diaphragm also the weight of the thoracic viscera, and, to a
(•(>rtain extent, the liver and other abdominal organs.
Further, through the sternal attachments of the shoulder
girdle and the anterior situation of the arms, there is to a
certain extent also, a drag downward and forward on the
dorsal sjiine by tliem.

If the spine, as a whole, is viewed in jjrofde in either a
skeleton or a fresh specimen, it will be seen that a vertical
line drawn througli the liodies of the cervical vertebra' will
pass anterior to the dorsal vertebra\ not touching them, but
in the lumbar region sucli a line will again reach the verte-
l)ral bodies. Thus, from an anatomical standpoint, we may
lonclude that the meclianics of the spinal column decidedly
])redispose to a ilnrsnl convexity, or kyphosis, even without
the addition of disease, which the continuity of the verte-
bral bodies and interverbral fibrocartilages antagonize
anteriorly, and the ligamenta flava, inter- and supraspinalia
posteriorly.

Secondly. — From the pathological findings in caries of tlie
vertebra?, since the time of Sir Percival Pott (1779), ob-
servers have noted that the less compact bodies of the ver-
tebrfB are the seat of the tubercular osteitis, softening and
disintegration and not the denser articular and transverse
processes, as a rule. As a result of this in tintreated, mal-
treated and neglected cases, the cliaracteristic deformity

'Bradford and Lovett, Orthopedic Surgery, 3d edition, 1899, ."JS.
3 Memoirs de I'Aciidemie royale de cliirurgie, Paris, 17G8, tome (4).
■•Transactions American Orthopedic Assoc, vol. iv, 244.

has occurred, i. e., the superior and inferior edges of the
bodies of the involved vertebra; have come into closer con-
tact anteriorly and the spinous processes are more widely
separated than is normal (Fig. 1). In addition, unless means
are adopted to cheek this, the healthy vertebral bodies will
come into contact with those diseased, and from the trau-
matic irritation jiroduced thereby and the contiguity, the
healthy vertebrre will also become involved in the process
and so the diseased area will extend.

What, then, can we gather from this, as the indication
for the treatment to combat this normal and pathological
tendency to kyphosis? Manifestly it is the nuxintenance of
hyperextension of the spine until all danger of extension of
the tubercular process is passed and firm cicatrization has
occurred from the layer of non-tubercular granulation tissue,
which is converted in time into fibrous tissue, cartilage or
bone and locks the vertebral bodies or processes together
inseparably by ankylosis.

I have illustrated this diagrainmatically (Fig. 2): Let
Fig. 2A represent two healthy vertebrae seen in profile. The
parallel lines represent the superior and inferior planes of
those bodies. The centre of gravity or weight-bearing line
is indicated by the dotted line, seen to pass through the
centre of the vertebral bodies. The alignment of the
spinous processes is seen to be straight.

In Fig. 2B we see the result of an untreated tubercular
process where the bodies have collapsed, the planes of the
superior and inferior surfaces converge and meet anterior
to the vertebral column and the spinous processes are widely
separated. The centre of gravity line is thrown further
forward, tending to increase the deformity. The separation
of the spinous processes shows the characteristic contour of
the hump-back.

In Fig. 2C is shown what should be the aim of treatment;
the separation of the vertebral bodies as far as the liga-
mentous and muscular attachments will permit; the throw-
ing of the centre of gravity back on the articular processes
and the crowding together of the spinous processes. We
cannot say that a true separation of the vertebral bodies
really occurs by hyperextension before extensive bone de-
struction has taken jilace, Init certainly intravertebral pres-
sure is lessened on the bodies thereby. On the other hand,
Bradford and Cotton's '' experiments lead us to suppose in
extensive unhealed disease sucli a separation certainly occura
in hyperextension.

To meet this aim of treatment, in the latter part of 1891
I presented before the Johns Hopkins Medical Society ° what
I termed an api)aratus for applying plaster jackets on the
plaster jacket stool on wliicli the patient sat, with the pelvis
fixed, the arms extended upwards and backwards, and trac-
tion was made on the head by means of a head-sling. The
result of this attitude on the spine was lordosis. In that
paper, as far as I can find out in the literature, T first called

5 Boston Med. and Surg. Jour., Sept. 30, lilOO, 370-28(1.
S.Johns Hopkins Bulletin, No. 4"), February, 180.5, and Medical News,
March 2;i, 1895.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

attention to and demonstrated clinically the importance of
extending the spine backwards (hyperextension) and the
maintenance of this position by means of plaster of Paris
jackets for the prevention or correction of tlie natural ten-
dency of the deformity of Pott's Disease (Fig. 3). However,
Hadra in 1891 suggested the same principle by wiring the
spinous processes together, " thereby relieving the vertebral
bodies," but in the article it is stated he lias not done this
operation in Pott's Disease.' Other methods to accomplish
the same end were published by otlier observers shortly
after.

Chipault published on March 9, 1895, his method of wiring
the spinous and transverse processes in Pott's Disease after
" forcible correction " of the deformity under anoesthesia by
manual traction on the head and extremities and pressure
on the gibbosity.*

Calot published a paper on similar operations in 1896.'

Goldthwait reported, ih 1898, his and Metzger's excellent
method of hyperextension, without anfesthesia, in which the
patient lies supine on two strips of steel, that portion of the
spine above the knuckle being unsupported and gravity act-
ing as the correcting force."

Eedard in the same year published his method of mechan-
ical traction in a prone position with anaesthesia and manual
pressure on the boss."

In 1899 I presented to the American Orthopedic Associa-
tion " my plaster jacket stool, supplemented with a pressure
rod (Fig. 4), to control the point at which hyperextension
was to be made (viz., at the kyphosis) and called the appa-
ratus " The Kyphotone " (^ycsoc, hunchback, and rei-y^r^, to
extend). I found that without pressure on the knuckle in
mid-dorsal cases, the lordosis, or hyperextension, frequently
was more marked in the lumbar region than in the region
of disease and more marked than was desirable, but the pres-
sure rod on the knuckle obviated this, making the region
of the gibbosity the centre of this arc (Figs. 5, 6 and 7).

The comparative value of suspension and hyperextension
in the correction of the deformity of Pott's Disease is well
shown in the photographs (Figs. 8 and 9). In Fig. 8 (a
double photographic exposure) the lower photograph shows
the child sitting on the kyphotone and the knuckle is well
seen against the background. The upper photograph shows
the child suspended by the Sayre head-sling and the knuckle
is virtually of the same size it was before traction was made.
In Fig. 9 we see traction has been made on the head, the
arms have been carried upwards and backwards, the pelvis
has been made fast and the pressure-rod has been applied,
causing hyperextension at the knuckle, with the result that
the spine is virtually straight.

' Hadra, Trans. Amer. Ortbo. Assoc, vol. iv, 20.5.
*Cl)ipauU, Medicine Moderne, No. 20, Sixieme Ann^e.
9 Calot, Trans. Acad. M^d., Paris, 1896.

I" Goldtliwait, Trans. Amer. Ortlio. Assoc, vol. ir, 1S89.; Boston Med.
and Surg. Jour., July 28, 1898.

"Eedard, Archivlo di Orthopedia, 1898, Fasc. 2.

'■Transactions, vol. xii, and N. Y. Med. Jour., May 12, 1900, 716.

This year I wish to present two recimibent kyphotones
which carry out the same mechanical principles of hyper-
extension.

The larger is similar in many details to the one attached
to the office stool, but differs in having the patient lie in a
supine position on a plate or pelvic crutch instead of sitting
up. The main bar slides in a solid metal block and thus
can be lengthened or shortened to adapt itself to the pa-
tient's size.

The pressure-rod, attachments for hands and head-sling
are similar to the upright kyphotone (Figs. 10 and 11).

The smaller kyphotone is quite simple, inexpensive and
can be easily taken ajjart and carried in a satchel to a pa-
tient's house. It consists of two solid bases and uprights,
one surmounted by a plate of sullicient size to support the
pelvis and the second by a small plate to press upwards
against the knuckle. This latter plate is adjustable and can
be raised or lowered to increase the pressure and vice
versa. The distance between the uprights can also be regu-
lated by a rod attached to the bases by set-screws. The plate
of the pressure-rod is incorporated in the plaster jacket
during its application, but can be easily slipped out after the
patient is removed from the machine by making an incision
on one side of the pressure-rod in the plaster, which at this
stage has not entirely hardened (McKim's modification).
Then the opening thus made can be entirely and easily closed
by moulding together the moist edges (Figs. 12 and 13).

Both of these recumbent kyphotones have been made to
meet the need of acute or early cases or those with external
pachymeningitis with paraplegic symptoms, in which it is
detrimental to even sit up momentarily until the head-sling
is adjusted and the superincumbent weight removed.

I have made an additional use of the larger recumbent
kyphotone, and had attachments made for the mechanical
correction of scoliosis of a severe and advanced grade, and I
have used it also as a twisting correction machine daily on
such cases or to obtain a corrected position in which it is
deemed advisable to hold the patient constantly by means
of a plaster jacket. Lovett has of late shown the value of
hyperextension in the treatment of scoliosis," but the scope
of this paper will not permit of further mention of this use
of the recumbent kyphotone (Figs. 1-1, 15 and 16).

The question of which of these machines we shall use to
prevent, correct or improve the deformity of Pott's Disease
depends on the pathological condition we find the spine in,
as shown by its flexibility, the size of the knuckle not neces-
sarily being a determining factor of the latter.

(1) Earliest Stages. — At this period there is no deformity
to correct, but the child will indicate by its posture, carriage
or gait, grunting respiration, jjain, niglit cries, muscular
spasm or some of the characteristic symptoms, that spinal
trouble is present. The region can be located by an expert
and prevention of deformity obtained by plaster jackets ap-
plied in slight hyperextension on the small recumbent
kyphotone.

IS Boston Med. and Surff. Jour., June 14, 1900.

Febkuary, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

At this stage caseation and conglomeration of the tuber-
cles is beginning and traumatic contact from pressure of the
healthy adjacent vertebra; is ripe to help break down the
diseased vertebral body.

Unfortunately, the orthopedic surgeon rarely has an op-
portunity to try his skill at preventive medicine, as the gen-
eral practitioner and general surgeon, for that matter, either
retain the case themselves, using antiquated methods and
recall hazily one lecture at college on " spinal disease," in
which same "orthopedic lecture" nine times out of ten are
given scoliosis, club-foot, flat-foot, bow-legs and all the
rest, as well as " anteroposterior curvature." Or else the
treatment (?) is referred to that paragon, the blacksmith
— instrument-maker and pathologist.

(2) Beginning Deformity. — Thanks to the above treat-
ment ( ?) or to the fact that the general practitioner et ah
has been so busily engaged in diagnosticating the thoracic
(ir abdominal pain he has failed to strip and roll the child
over and look at its back, the knuckle is discovered by the
child's mother. In such a case the vertebral body has par-
tially broken down and abscess-formation has begun. Cor-
rection may be obtained by gravity with the small recumbent
kyphotone and maintained by a plaster Jacket.

(3) More Advanced Cases. — In a case in which several ver-
tebral bodies have broken down, and in wliich some adhesions
or filirous ankylosis are ujst starting to form, either the large
recumbent or upright kyphotone may be necessary to cor-
rect, with head-sling traction and pelvic fixation. It is at
times astonishing to see a large hump disappear under this
treatment (Figs. 8 and 9).

(4) Neglected or A/ihijlosed Cases. — If the ankylosis in a
case is solid and condensing osteitis has taken place, no
extreme force is justifiabU. Pain should be the guide to the
amount of pressure or traction force used. Even, however,
in large knuckles or 'humps, it may be found the ankylosis
is not solid, and it is certainly justifiable to lessen the de-
formity of such a case by one of the more powerful kypho-
tones and allow the spine to heal in an improved position.

The method suggested by Bradford and Vose '* would
seem also applicable to the first two of the foregoing varie-
ties. This method consists of allowing the child to lie on
its back and be slung in a position of hyperextension by a
piece of firm cloth passing under the kyphos. This cloth,
after passing around the side, is attached to a pulley, by
means of which the hyperextension of the spine can be regu-
lated.

When we consider the three regions of the spine to which
hyperextension in Pott's Disease may be applied, we find
difficulties confront us in each. In the cervical region with
its normal lordosis the application of plaster of Paris ban-
dages presents difficulties both as to efficiency, comfort and
the avoidance of a bungling mass around the neck. A child's
neck is so short, and with a traction head-sling on, it is next

"Annals of Surgery, 1899, vol. xvii, 323.

to impossible to apply an efficient bandage. The best plan
is to use a steel back-brace with a head-support, but this
will not correct the deformity. Instead of the head-sup-
port, or in conjunction with it, I have of late used a steel
back-brace extending upward to or just above the kyphos
and at this point had two buckles attached for a padded
webbing strap to pass around the front of the throat. By
tightening this strap the falling forward of the cervical seg-
ment can be limited or lessened, and it is astonishing how
tight this strap can be borne. At first the patient gets
quite livid in the face, but in a day or two the circulation
adapts itself to the new condition and the child involun-
tarily holds the neck back, away from the strap, by means
of the posterior muscles. I have seen no embarrassment
of respiration and the superincumbent weight of the head
is transferred to the healthy articular, transverse and
spinous processes.

From the sixth (6) dorsal vertebra upward, our depend-
ence must be ]ilaccd on the steel back-brace with supple-
mentary straps to hold the shoulders and neck well back-
wards. From tliis point downwards the plaster jacket can
be used, applied in hyperextension, but owing to the normal
kyphosis, extreme hyperextension is difficult and entire cor-
rection of a severe deformity is rarely possible, except in
very early cases. In the lumbar region, where normal lordosis
already exists, it is easy to overdo the hyperextension with
the result that the patient has a pot-bellied or sway-backed
appearance. This can be avoided by making the head trac-
tion upward and slightly forward (not upward and backward) ;
or, by a modification one of my assistants, Compton Eiely,
has made, to exert pressure against the anterior superior
spines in front and behind the trochanters major to prevent
tilting forward of the pelvis, he having noticed in the ma-
jority of cases that the chief part of the lordosis was pelvic
(Fig.' 17).

Another method of obviating this excess of lordosis is to
flex the thighs on the body, thereby relaxing the psoas pull
on the lumbar spine and preventing the rotation forward of
the pelvis.

I have not attempted the use of anaesthesia with these
methods of aiiplying correction to Pott's Disease, but rather
avoided it as unnecessary and dangerous. The pain caused
is inconsiderable in reduction and the resulting jacket is a
relief to the painful symptoms previously present. These
methods permit of the application of mechanically correct
jackets, t. e.. those in which firm, even pressure is exerted
against the three important points, the kyphos behind, the
whole length of the sternum and ribs and the anterior
spines of the ilia in front.

As I have said, in spines in which I suspect ankylosis I do
not use great force, simply rendering them as straight as
possible, short of pain. So-called " forcible correction," by
which is meant manual traction and pressure under an
ancesthetic, has but few adherents here in America, the
majority of us feeling loath to tear by great force structures
we could not appreciate on account of the anesthetic, pain

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

being eliminated. Fatal and untoward results have been
reported by Sherman," Jonnesco," Lorenz " and others.

The tracings (Fig. 18) show the results in a few cases of
the Hospital for Criijpled Children. The stated duration
of the disease is indicated under the initials of the case and
it can be easily seen how much better results, as a rule, are
obtained ultimately in cases treated early. On the other
hand, when the size of the gibbosity is considered, quite an
unexpected and appreciable improvement is shown in some
of the eases.

As to the comparative value of the three machines, the
upright kyphotone finds more general application than the

For conclusions as to these methods of correcting the de-
formity of Pott's Disease and applying plaster jackets, I
would say:

First. The jackets thus applied fix the spine in
the most advantageous position for lessening the tendency
for the production of deformity.

Second. The rapidity and ease with which jackets may
be applied.

Third. These methods are applicable to mid- and lower-
dorsal and lumbar caries. Above the sixth (6) dorsal, a steel
back-brace with head-support or throat-strap must be used.

Fourth. It seems comfortable to the patient, as the

S IE
1897 11"

Fig. 18. — Tracings from (12) out-patienfs treated hy kyphotones. Above each line is
the date; to the left are the initials of the case and the duration when first seen. Between
each pair of lines is given ihe vertebra chiefly involved

other two, as in the stage in which the majority of caset
present themselves the knuckle is somewhat advanced in
formation and slight adhesions exist; further, the patient
can be viewed from all sides and the ultimate appearance of
the jacket is at all times apparent. It is the quickest
method, all things considered.

For the early stages the small kyphotone acts admirably,
and for cases with paraplegia or acute sjTnptoms with an
advanced kyphosis, the large recumbent khyphotone is
needed.

•5 Pacific Record of Med. and Surg., October 1.5, 1898, 73.
■'Communication to Twelfth Internat. Congress of Med.
" Deutsch med. Wochen., 1897, 556.

thorax is well supported and the superincumbent weight is
removed from the diseased vertebral bodies to the healthy
articular processes. Quite an appreciable gain has been no-
ticed in the nutrition of patients after this method is used,
due largely to the increased lung-expansion, which the
posture renders possible.

Fifth. Absolute immobilization of the jjatient in the de-
sired corrected position is obtained, one person being able
to apply the methods without assistants to steady the pa-
tients, as nothing can slip at the most important moment.

Sixth. Hyperextension has been used constantly in the
Hospital for Crippled Children in applying jackets on all
suitable cases, from 1895 to the present time, and its effi-
cacy has been demonstrated to our satisfaction clinically.

THE JOHNS HOPKINS HOSPITAL BULLETIN. FEBRUARY. 1901.

PLATE XI.

Tiihcrcuhir ioflciiiin;.

Fig. 1 SjiiiK'. Lower Dorsal Region. Child. Vertical antero-
posterior section. One intervertebral disk destroyed and the anterior
adjacent edges of vertebral bodies softened and disintegrated. Exten-
sion of the process backward to dura, and forward among prevertebral
ligaments. Moderate knuckle. iNicholsi.

Fi(;. 2. — Diagram showing [\) Normal position of adjacent vertebrse.

(B) Falling forward of the vertebral bodies in caries of the spine.

. — The planes of the vertebral bodies.

. — The line of the centre of gravity and of the super-
incumbent weiiibt.

Fig. .<{. The oritriuiil )'laster jacket stool. is;i,"i

THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1901.

PLATE XII.

THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY. 1901

PLATE XIII.

Fig. 8. — A double pliotogfiiphic- cxposuri".
Lower figure shows child (II. T. i iu sittinir |"isture.

Upper tiijurc shows rhihl ill. T.I snspciuh-d liy lu';ul, with no ri-diu'tioii
in the kypliosis.

Fir., il. —Shows cliild (II. T. ) hyperc-xteiuhHl with obliterutiou of the
kyphosis.

Fio. 10. — Case (\V. W.) showiim- di'forinit\ . Kyphotoue sci'U on the ri^■ht.

Kic. 11. — Case iW. W.) sreu lOi the hirue ri'cuinhent kyphotone.

Fic. \2. — Case (B. H.) and small reninibcnt kyidiotun.-.

Fig. 13. — Case (B. H.) showint;- complete (dditcration of the deformity.

THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1901.

PLATE XiV.

Fig. 14 — Case (C. N.) scolioti

Fid. ifi. —Case (C. N.) sliowiiiy' correction
effected on large recnmbent kyphotone
anil maintained by a plaster jacket.

Fiii. 17 — Conipton Riely's moditication, adjust-
able by set-screws to any pelvis. Arrows
indieate imints where pressure is made.

o. I.-,._Case (C. N.) on large recumbent kyi>liotone.

February, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Seventh. Aside from the danger of excessive and unequal
force being used manually by several persons making trac-
tion for " forcible correction " under an anaesthetic, these
methods enable one operator to adjust to a nicety his pres-
sure and traction without an anesthetic and further enable
him to make his diagnosis as to the pathological stage the
process has reached, which the size of the deformity does
not always tell, in regard to the degree of ankylosis.

EeCENT BlIiLIOGRAPHY ON PoTT's DISEASE.

Anders: Arch. f. Chir., 1898, Ivi, 703.

Aue: Ann. Euss. Chir., St. Petersburg, 1898, H. 3, 472.

Babaeei: Eaceoglitore med. Forli.. 1897, xxiv, 25.

Barragony y Bonet: Eev. de ther. med. chir., 1899, 3-12.

Banning: Interstate Med. Joiir., St. Louis, June, 1900.

Bilhaut: Ann. de chir. et d'orth., Paris, 1898, xi, 4, 140;
Med. enfant., Paris, 1897, 318; Ann. de chir., et d'orth.,
Paris, 1897, 193; Proces verb, Congr. de chir. franc, 1897,
xi, 327.

Blondez: Ann. de la Soc. Beige de chir., Brussels, 1898,
vi, 72.

Bobrofl: Med. obozy., Moscow, 1897, 696.

Bouquet: Eev. d'orthop., Paris, 1900, xi, 217-218.

Bradford and Vose: Annals of Surgery, 1899, xvii, 223.

Bradford: Med. Press and Circ, Lond., n. s., Ixix, 13G-
137; Eev. mens. mal. I'euf., Paris, 1900, xviii, 450-455.

Bradford and Cotton : Bost., M. and S. J., 1900, cxliii, 12,
277-283.

Braun: XXVII Congr. deutsch. Chir., 1898.

Broca: Presse med., 1897, 213.

Brun: Ibid.

Buell: Pacific Coast J. Homoeop., San Fran., 1899, vii,
1-11, 4 pi.

Calot: Arch. prov. de chir., 1897, vi, 557; Eev. de ther.
med. chir., 1897, Ixiv, 573; Transactions of the Clinical So-
ciety of London, 1897-98, xxxi, 26; Eev. de chir., Paris, 1897,
xviT, 1019; Proces verb., Congr. de chir. franc, 1897, xi, 299;
Wien. med. Presse, 1897, No. 35.

Capelli: Tribuna Med., Milan, 1898, xii, 152.

Carleton: Yale Med. Jour., New Haven, 1900, vi, 315-
322.

Chipault: Presse med., Paris, 1897, 240; Eev. de chir.,
Paris, 1897, xvii, 1026; Assoc franc de chir., Paris, 1897,
xi, p. 352 (Proces verb.); Transactions of the Clinical So-
ciety of London, 1897-98, xxxi, 43; Du mal de Pott, Paris,
1897; Gaz. des hop., 1897, xxi, 197; Ibid., 1897, Ixx, 900.

Clarke : British Medical Journal, London, 1898, i, 429.

Czajkowski: Gaz. Kek. Warszawa, 1898, xviii, 64.

D'Addosio: Puglia Med., Bari, 1898, vi, 116.

Delcroix: Presse med. Beige, Brussels, 1897, xlix.

Dane: Pediatrics, K Y., 1900, x, 14-17.

De Eothschild: Proges med., Paris, 1898, viii, 497.

Ditman: Euss. Arch. Pathol. Klin., St. Petersburg, 1898,
V, 207.

Drehmann: XXVII Congr. deutsch. Chir., 1898.

DiTcroquet: Deutsch. med. Woch., xxv, 556; These de
Paris, 1898; Twelfth International Congress at Moscow.

Freeman: Annals of Surgery, 1898, xxvii, 463.

Freiberg: Transactions of the Academy of Medicine,
Cincinnati, 1897-98, 213; Cincinnati Lancet Clinic, 1898, xi,
151.

Galloway: Canada Journal of Medicine and Surgery,
1899, v. 77.

Gayet : La Gibbosite dans le mal de Pott, Paris, 1897.

Gevaert: Ann. de la Soc. Beige do chir., Brussels, 1898,
vi, 115.

Gibney: Medical News, New York, 1898, lxxiii,_ 391;
Transactions of the American Orthopedic Association, 1898,
xi, 83; New York Medical Journal, 1898, Ixvii, 427.

Golthwait: Transactions of the American Orthopedic
Association, 1898, xi, 897.

Guibal: Bull, et mem. Soc. Anat. de Paris, 1899, Ixxiv.
945-956.

Greenwell: Fort Wayne Med. J.-Mag., 1899, 413-416.

Guyot and Oilier: La Gibbosite du mal de Pott, Paris,
1897.

Hallstrom: Duodecjmus; Haelsink, 1897, xiii, 344.

Haudek : Wien. med. Woch., 1899, xlix, 1930.

Helferich: Zcitschr. f. orth. chir., 1897, v, 342; Zeitschr.
f. prakt. Aerzte, 1897, No. 16, 541.

Heusner: Deutsch. med. Woch., 1897, xxiii, 773.

Huhn: Arch. f. Klin, chir., Ivi, 1898, 697.

Iloffa: Miinch. med. Woch., 1898, xlv, 545; Deutsch. med.
Woch., 1898, Nos. 1 and 3; Arch. f. klin. Chir., Ivii, H. 3.

Hoffa: Miinchen, 1900, 28 pp., 10 figs., Seitz u. Schauer.

Hoffmann: Pediatrics, N. Y., 1900, x, 50.

Jeannel: Arch. prov. de chir., 1897, vi, 383.

Joachimsthal : 70 Naturf. u. Aerzteversamml., Diissel-
dorf, 1898.

Jones: Liverpool Medico-Chirurgieal Journal, 1898, xviii,
154; British Medical Journal, 1897, ii, 336.

Jonnesco: Spitalul. Bucarsci, 1897, xvii, 244; Annals of
Surgery, Philadelphia, 1897, 789; Arch, de sc med. de
Bucharest, Paris, 1898, iii, 1; Eev. Mens, de Med., Madrid,

1898, iii, 147; XII Internat. Congr. Chir.

Jonnesco and Melun: Eevista de chir., 1897, No. 5.

Joseph, J.: Deut. Med. Woch., Leipz. u. Berl., 1900,
xxvi, Ver.-Beil., 171-172.

Kirmisson: Bull, et mem. Soc. de Chir. de Paris, 1900,
xxvi, 291-292.

Konig: XXVI Congr. deutsch. Chir., 1898.

Krause : Ibid.

Kummell : Ibid.

Lacroix: F. Arsenal med.-chir. contemp., Paris, 1900, vii,
21-28 and vii, 41-46, 6 tigs.

Lange: Centrbl. f. Chir., 1898, No. 12; Wien. Klinik,

1899, xxv, H. 1.

Levassort: Eev. de chir., 1897, xvii, 1024; Proces. verb.,
asso. franc de chir., 1897, xi, 349; Eep. de therap., Paris,
1898, XV, 447.

Ligorio: E. Eiv. di Chir., Torino, 1899, 1, 65-69.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

Lorenz: Deutsch. med. Woch., 1897, 556; Zeitschr. f.
orth. chir., 1897, v, 343; Twelfth luteruational Congress at
Moscow.

Lorett: Boston Medical and Surgical Journal, exxxviii,
p. 328.

Malherbe: Gaz. med. de Nantes, 1896-97, xv, 132; Ann.
de chir. et d'orth, 1897, 218.

Martin: Miin. Med. Woch., 1899, xlvi, 1444.

Menard: Gaz. med. de Paris, 1897, i, 231; Eev. de chir.,
Paris, 1897, xvii, 526; Presse med., 1897, 13; Bull, et mem.
Soc. de chir. de Paiix, 1897, xxiii, 363; Eev. d'orth., 1899,
173, 301, 379. Ibid., 1900, xi, 123-146.

Menard and Guibal: Rev. d'orth., 1900, No. 1, 35; Bull,
med., Paris, 1899, xiii, 856.

McCurdy: Penn. M. J., Pittsburg, 1899, iii, 62-69.

Meneiere: Med. mod., Paris, 1899, x, 313-316.

Meyer: Zeitschr. f. orth. Chir., 1898, vi, 201.

Miilot: These de Paris, 1898.

Monod: Bull, et mem. Acad, de med., Paris, 1897,
xxxvii, 695; Gaz. des hop., Paris, 1897, Ixx, 656; Presse m6d.,
1897, No. 57.

Murray: British Medical Journal, 1897, ii, 1630; Amer-
ican Journal of the Medical Sciences, May, 1898.

Myers: Am. Pract. and News, Louisville, 1900, xxix,
227-228; Med. Times and Reg., Phila., 1900, xxxviii, 118-119.

Nasse: Berlin, klin. Woch., 1898, xxxv, 13.

Nebel: Samml. klin. Vortriige, Leipzig, 1897, No. 191.

Pean: Twelfth International Congress at Moscow.

Peckham: Transactions of the American Orthopedic
Association, 1898, xi, 109; Archives of Pediatrics, 1898, :fv,
641.

Phelps: Post-Graduate, 1899, xiv, 702; Med. Register,
Richmond, Va., 1899, ii, 397-420; Trans. Med. Soc. St., N.
Y., 1899, 209-235.

Phocas: Asso. franc, de chir., 1897, xi, 322; Med.
moderne, 1898, No. 52; Rev. de chir., 1897, xvii, 1021.

Redan et Loran: Am. X-Ray J., St. Louis, 1899, iv, 540-
541.

Redard: Rev. de chir., Paris, 1897, xvii, 1021; Ass. franc,
de chir., 1897, xi, 312; British Medical Journal, 1897, ii,
1642; Twelfth International Congress at Moscow.

Ridlon: Chicago Medical Recorder, 1898, xiv, 134; Med-
ical News, New York, 1898, Ixxiii, 484; Transactions of the
American Orthopedic Association, 1898, xi, 120; Journal of
the American Medical Association, 1898, xxxi, 71.

Salayer and Sousa: Med. Contemp., Lisbon, 1897, xv,
237.

Schanz: Deutsch. med. Woch., 1898, 387; Zeit. f. Ortho.
Chir., Stuttg., 1900, vii, 531-533.

Schatalow: Med. Obos., 1899, Ii, lift. 5; Abstr. Med.
der Gegenw., Berl., 1899, 11, 443.

Schede: Zeitschr. f. prakt. Aerzte, 1898, vii, 485; Arch.
f. klin. Chir., 1898, Ivii, 507; Twelfth International Congress
at Moscow.

Sherman and Brunn: Pacific Medical and Surgical Re-
corder, 1898-99, xiii, 73.

Subotin: Rev. illustr. polytech. med. et chir., Paris, 1899,
xii, 90-92; Centrbl. f. Chir., 1898, 460.

Smith: Lancet, London, 1898, ii, 497.

Tilanus: Tijdschr. v. Geneesk., Amsterdam, 1898, xxxiv.

Toles: Southern California Practitioner, 1898, xiii, 401;
Ibid., August, 1899.

Townsend : Lancet, Lond., 1900, 1, 232-233, 1 fig.

Trendelenburg: Abstr. Ann. Surg., Phila., 1900, xxxi,
667-668.

Tubby: British Medical Journal, 1897, ii, 1501; Practi-
tioner, 1898, Ix, 28.

Tubby and Jones : Transactions of the Clinical Society of
London, 1897-98, xxxi, 15.

Twitchell: J. Med. and Sc, Portland, 1900, vi, 41-49.

Verger et Lanbie: Progres med., Paris, 1900, 3, 5, xi,
49-53.

Villemin : Ann. de med. et chir. inf., Paris, 1900, Iv, 253-
260.

Vincent: Lyon Med., 1897, Ixxxv, 333; Ann. dc chir. et
d'orth., 1897, xxiv, 207.

Vulpius: Centrbl. f. Chir., 1897, xxiv, 1257; Deutsch.
med. Woch., 1898, xxiv, 379; Arch. f. klin. Chir., 1898, Mi;
Twelfth International Congress at Moscow; Centralbl. f. de
Grenzgeb., etc., 1899, ii, 673.

Wirt : Bull. Cleveland Gen. Hosp., 1899, 1, 30-39.

Wiart: Rev. de chir., Paris, 1898, xviii, 777; Ibid., 1899,
xx.x, 33, 170.

Wider: Fork. Svens. Luk. Sallsk. Sammoek., Stockholm,
1898, 3.

Williams: Lancet, London, 1898, i, 1352.

Wolff: Berlin, klin. Woch., 1898, Nos. 7, 8.

WiiUstien: Arch. f. klin. Chir., 1898, Ivii, 485; Centrbl.
f. Chir., 1898, xxv, 705.

Young: Internat. Med. Mag., Sept., 1900.

Zenatski: Wratsch., St. Petersburg, 1897, xviii, 877.

TWO EXAMPLES OF BENCE JONES' ALBUMOSURIA ASSOCIATED WITH MULTIPLE MYELOMA.^

A PRELIMINARY REPORT.

By Louis P. Hambuegek, M. D.,
Assistant in Medicine, Johns RopHns University.

albuminous body having peculiar properties. It had been
voided by one of his patients in large quantity — about 3,500
cc. — in the twenty-four hours. We examined it and found
that it afforded the reactions which I shall demonstrate to
vou to-ni<;ht.

On the 13th of last month. Dr. Iglehart brought me a
specimen of urine with the remark that it contained an

' Deitnnstratiiin before the Johns Hopkins Hospital Medical Society,
November 5, I'.IOO.

February, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

As you see, it is very pale, of an acid reaction, with a spe-
cific gravity of 1,004. It gives a white ring when floated
over nitric acid. Heated to a temperature of about 55^,
a heavy milk-white precipitate appears. Boiled, the fluid
becomes clearer, only to become more turbid on cooling.
The addition of acetic acid to the fluid after reaching its
maximum turbidity causes it to become clear again. A few
drops of nitric acid yield a precipitate which dissolves com-
pletely on boiling and reappears on cooling. In the Esbach
albuminometer the proteid content reaches 0.27 per cent.
The urine gives a strong biuret reaction. Let it be added
that no easts were seen even in a centrifugalized specimen.

We recognized that this condition was no ordinary albu-
minuria. It is not the usual urine of nephritis, although the
positive Heller's test alone might lead one astray. But the
usual albumins of albuminuria, after being precipitated by
heat, are not dissolved by the addition of a small quantity of
acetic acid; they do not tend to redissolve on boiling; the
nitric acid precipitate does not dissolve on boiling and reap-
pear on cooling and the biuret reaction is wanting. The
substances which do offer these reactions are the albumoses,
the condition is that of albumosuria, and so I designate it
in the present instance.

From an acquaintance with the literature on the subject,
I was able to point out to Dr. Iglehart that this condition
of so-called albumosuria in such a marked degree was an
accompaniment of sarcomatosis of the bone, and, indeed, of
a peculiar variety originating in the marrow and known as
myelomata, new growths affecting for the most part the
skeleton of the trunk — the vertebrae, the clavicles, the
sternum and the ribs. Whereupon he recalled that his pa-
tient had had on two occasions most intense pain in the ribs
and had lost much weight during the past three months.

So convinced was he by the data which were presented to
him, that he gave a member of the family the serious prog-
nosis which the condition merits.

Dr. Iglehart has given me further details of this peculiar
illness. He was called to see the patient, a lady 49 years of
age, in August, 1900. Previously healthy, she was sud-
denly seized at this time with sharp pain over the 9tli left
rib near its cartilaginous attachment. The pain was severe
and increased on deep inspiration. There was tenderness on
pressure over the painful point. Neither crepitus nor a
friction rub was present. The condition so resembled a frac-
ture that he considered the patient had injured the rib, but
he could elicit no history of trauma. Within three weeks the
pain had disappeared. She was again seen in September, this
time complaining of nausea without apparent cause. Her
general health had suffered; she had lost thirteen pounds
in weight.

Early in October she was seized a second time with pain,
now in the region of the 8th right rib in the mid-axillary
line. It was at this time that the remarkable urinary con-
dition was discovered. The patient herself had noted that
since the past summer she had drunk more water than usual
and had voided a larger quantity of urine.

Dr. Osier saw the patient on November 3d, two days ago,
and aside from a slight pallor of the visible mucous mem-
branes, the physical examination was negative.

In short, however absurd it may seem at first thought,
from examinations of the urine I was confident I had estab-
lished the probable diagnosis of new growth of the bone-
marrow.

Excepting in diseases of the urinary tract itself, I know
of only one other instance in which, without having seen the
patient, the diseased organ may with great probability be
determined from an examination of the urine. I refer to
the presence of leucin and tyrosin in the urine as a sign of
widespread destruction of liver siibstance.

Following the recognition of this example of albumosuria
with its consequent diagnosis, Dr. Osier called my attention
to the patient who lies before you, and it is to his courtesy
that I am indebted for the privilege of reporting an abstract
of her history.

The patient is a colored woman 50 years of age, who en-
tered the medical clinic of the Johns Hopkins Hospital
October 10, 1900, complaining of "rheumatism" and a
" sprained hip." Kegarding her family history she can
only recall definitely that her father died of old age; that her
mother, eight brothers and a sister have died from causes
unknown to her; and that a sister is living and well.

She suffered the diseases of childhood and twenty-four
years ago had " rheumatism " in both knees. Ten years
ago she contracted grippe, and since then has had a cough
each winter.

For about a year she has had pain in the region of the
right groin and hip. One night last June, while picking
up a bucket of coal, she experienced a remarkable sense of
lengthening in the left arm and the next morning found
that she could not raise it to her head because of pain and
a feeling of weight. A week later the right arm became
affected. She had pain here as well as in the shoulder,
back of neck and chest. About this time the patient no-
ticed a swelling the size of a hen's egg on the back of her
head. Pain and stiffness in the arms continued so that by
August she could neither cut her food nor feed herself.
Six days before admission to the hospital, while walking, the
right leg " gave away " without apparent cause. She fell
to the ground, and since then has not been able to stand or
walk. She has suffered great pain in the right hip. The
patient has lost much weight and strength during her illness.

As you see, she is markedly emaciated. The mucous
membranes are pale. Any movement of the body calls forth
great pain. Over the occipital region there is a round, soft,
fluctuating mass about 10 cm. in diameter, not adherent to
the skin, not movable on the deeper tissues, not tender. A
nodule three to four cm. in diameter is visible on either
clavicle over its inner third. The one on the left is a little
larger and more definitely circumscribed. It has evidently
eroded the bone, for manipulation causes pain and crepitus.
There is another tumor in the left supraspinous region
about 4 cm. in diameter and evidentlv connected with the

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

acromion process of the scapula. The right lower limb is
rotated outward and is abducted. The upper third ol the
thigh on this side is markedly enlarged and deformed by
the presence of a tumor, about the size of a child's head,
projecting from its postero-external aspect. It is firm and
tender on pressure. An attempt to move the limb causes
intense pain.

The lungs are clear on percussion. Here and there an
occasional crackling rale is heard with inspiration. The
poiut of the heart's maximum impulse is visible in the fourth
left interspace 7 cm. from the niidsternal liue. A systolic
murmur is audible at both the mitral and pulmonary areas.
The abdomen is distended and held rigidly. No masses are
to be felt. Neither the edge of the liver nor the spleen is
palpable. There is no general glandular enlargement. The
red blood-corpuscles number 3,51:8,000; the leucocytes, 4,500;
haemoglobin, 52 per cent. The relation of the diferent
varieties of white corpuscles is practically normal.

Now, here is a case in which the clinical picture is clearly
one of sarcomatosis of the bone. Does the urine exhibit the
characteristics of albumosuria ? As a matter of fact it docs.

The urine is turbid, light yellow, and GUO to 800 cc. are
voided daily. It is usually alkahne, though at times neutral
iu reaction. Its specific gravity varies from 1,013 to 1,030.
Heller's reaction is positive. Acidified and heated to a tem-
perature of 56° C, a heavy white precipitate appears. It
redissolves in part on boiling and returns on cooling. The
nitric acid precipitate disappears on boiling to reappear on
cooling. The mis:ture assumes a darker color and particles
of the precipitate adhering to the tube become pink. The
biuret reaction is marked. The proteid content measured
by the Esbach albuminometer varies from 0.3 to 0.6 per
cent. Finally, Dr. Dorothy Reed has, by saturating the
m-ine with ammonium sulphate and redissolving the precipi-
tate, demonstrated more precisely the albuminose nature of
this urinary constituent.

Some hyaline casts are present in the sedmient.

This second case needs no peculiar explanation, but our
diagnosis of neoplasm of the bone from examinations of the
urine of Dr. Iglehart's patient needs justification.

The occurrence ia the urine of proteids other than serum
albumin is an old observation. Almost thirty-five years ago
Lehmann ' made the statement that every albuminous urine
contained in addition to serum albumin, serum globulin; in
small quantity to be sure, but demonstrable. A little while
later Gerhardt,' in an endeavor to distinguish between renal
and febrile albuminuria, discovered in the urine a proteid
substance which was not coagulated by boiling. It was
present in small quantities in a variety of ailments, especially
in those accompanied by high temperatures — diphtheria,
typhoid and typhus fevers. Gerhardt designated the con-
dition " latent albuminuria." Subsequent researches con-
firmed and extended these observations and established the
close relation between the " latent albumin " of Gerhardt

sVlrch. Arch., 1866, Bd. xxsvi, 8. 125.
3Deut. Arch. f. Kl. Med., 1869, Bd. v. S. 215.

and peptone, the product of gastric digestion of albumin-
ous substances. Peptonuria of slight degree was found to
be an accompaniment of very many disorders: nephritis,
suppurative processes, acute yellow atrophy of the liver,
ulcerative diseases of the intestine, including typhoid fever
and carcinoma of the bowel; it was described as occurring
in scurvy. In short, so manifold were the conditions under
which small quantities of peptones were found iu the urine
that conclusions of much practical value could not be
drawn.'

With the well-known researches of Kiihne and Chittenden ''
on gastric digestion, the subject-of peptonuria entered a new
phase. You will recall that they established the existence of
a number of products intermediate between albumin properly
speaking and peptones, namely, the albumoses. Differing
among themselves in some details of solubility, they give
certain of the reactions of the albumins and like them are
precipitated by ammonium sulphate. Yet they partake of
the nature of peptones, for they are not precipitated by boil-
ing and they give the biuret reaction. In the light of
Kiihne and Chittenden's work, the conclusions concerning
peptonuria had to be revised; probably all instances of "pep-
tonuria " in the old sense are, as a matter of fact, examples
of albumosuria. Using special methods for their recognition,
albumoses have been found iu small quantities in the urine
of individuals suffering from various acute ailments; most
constantly, perhaps, in pneumonia, purulent meningitis and
.empyema.

Now, this acute, transitory or slight albumosuria cannot
be confused with the condition demonstrated to-night. In
this second class the presence of a comparatively large
amount of an albmuose-like substance so alters the behavior
of the urine toward the usual reagents that, as you have
seen, the condition can be recognized without the employ-
ment of a relatively elaborate method. Moreover, in addi-
tion to the comparatively excessive degree, the albumosuria
is persistent over long j^eriods of time, not transitory.

The first recorded observation in this class was reported
by Henry Bence Jones before the Eoyal Society of London
in 18-47.° He begins his communication thus : " On the
first of November, 1845, I received from Dr. 'Watson the fol-
lowing note, with a test-tube, containing a thick, yellow semi-
solid substance: The tube contains a urine of a very high
specific gravity; when boiled it becomes highly opake, on
the addition of nitric acid it effervesces, assumes a reddish
hue, becomes quite clear, but, as it cools, assumes a consist-
ence and appearance which you see: heat reliquefies it.
What is it ? " Bence Jones then proceeds to tell of his re-
searches. The urine was voided by a grocer 45 years of
age who had been " out of health " for thirteen months.
The urine showed variations in its coagulability; as a rule it
bore brisk and prolonged boiling without coagulating. With

* See Senator, Ueber Peptonurie, Deut. lied. Wochenscbr., 1S95, Bd.
21, S. 317.

sZeitschr. f. Biol., 1S83, Bd. xix, S. 1.59, 209; 1884, Bd. xx, S. 11.
«Pbil. Trans. Royal Soc, 1848, Pt. 1, p. 55.

Febkuakt, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

copper sulphate and caustic potash, it gave a claret color.
Most characteristic of all, Bence Jones thought, was its be-
havior toward nitric acid. This reagent gave a precipitate
which dissolved on heating and reappeared on cooling. On
January 3, 181G, he makes the note that the patient died,
adding, " The following day 1 saw that the bony structure of
the ribs was cut with the greatest ease and the bodies of the
vertebrae were capable of being sliced off with a knife." . . .
" The kidneys were sound both to the eye and microscope."

In 1850 Dr. Macintyre, who had attended the patient, pub-
lished some details of his illness.' The man dated his ail-
ment from a violent strain he had sustained in September,
1844, in vaulting out of an underground cavern. On com-
ing to the ground he felt as if something " gave away "
within his chest, with the further result that he suffered at
the time agonizing pain. The pain gradually subsided, but
about a month later he was again seized with sharp pain in
the chest, this time without an apparent cause. In the fol-
lowing spring he had another severe paroxysm, the pain was
referred to the right side between the ribs and the hip and
was considered j)leuritic in origin. These periods of intense
suffering alternated with periods of marked amelioration.
In time, however, every movement of the trunk was attended
with excessive pain. The poor sufferer became ansemic and
lost much weight and strength. Diarrhoea supervened, and
finally, after a sixteen months' illness, the patient died ex-
hausted. Physical examination failed to reveal the nature
of this painful and fatal illness. The remarkable urinary
reactions were noted two days before the specimen was
sent to Bence Jones. Post mortem the condition was desig-
nated " Osteomalacia fragilis rubra." The substance of the
sternum, ribs and vertebras was rarefied and crumbling; their
interior filled with a soft red gelatinous matter which micro-
scopically consisted of " granular matter, oil globules,
nucleated cells, constituting the bulk of the mass — a few
caudate cells and blood-disks extravasated largely amongst
the other cells, and giving the red color to the gelatiniform
mass."

Bence Jones' observation was almost forgotten, when in
1883 Kiihne ° published the result of an examination of urine
sent to him in 1869 with a clinical history by Stokvis, a Dutch
clinician. In the specimen he rediscovered the reactions of
Bence Jones and showed their close relation to those of his
own digestive albumoses. The patient died after a nine
months' illness which had been diagnosed as osteomalacia,
but an autopsy was not held.

Several years elapsed and a third case was described from
the clinical standpoint by Kahler and chemically by Hup-
pert.° A physician was the patient, the clinical diagnosis
was osteomalacia; the urine afforded Bence Jones' reactions
but post mortem instead of osteomalacia, a multiple round-
cell sarcoma of the bone-marrow; in other words, a mul-

tiple myeloma was disclosed. Thereupon Kahler suggested
that the presence of Bence Jones' reactions might be of
service in the diagnosis of multiple myeloma. Might not
the other two cases of so-called osteomalacia with albumo-
suria have been instances of this disease ? Bence Jones had
recognized that the association of the unusual urinary reac-
tions and the disease of the bone was probably not a
fortuitous one, for at the conclusion of his communication
he writes : " This substance must again be looked for in
acute cases of mollifies ossium." But it is Kahler who first
identified the pathological condition in these cases of bone
disease and albumosuria with the affection previously de-
scribed by V. Eustizky '" and called by him " Multiples
Myelom." The Italians give Kahler due credit, for Bozzolo's
ease is presented under the caption " Sulla malattia di
Kahler." " By the accumulation of recorded eases,
Kahler's surmise has become a fact.

To be brief, let me say that in the fifty years following
Bence Jones' presentation of his case before the Royal
Society, there were published and available for criticism
only four observations on albumosuria associated with
primary bone disease. Within the last three years, how-
ever, eight additional cases have been recorded. In eight
of the thirteen cases the autopsy has disclosed neoplasms
which must be classified as myelomata. In two cases the
tumors were visible, in the remainder there was no record of
a post-mortem inspection.'"

In this series are not included two examples of Bence
Jones' albumosuria which seem to be exceptions to the gen-
eral rule, since in one there was no ground (albumosuria
excepted) for assuming a disease of the bone, while in the
other there were, to be sure, changes in the bone-marrow,
but tlieir identity with those found in myeloma could not
be satisfactorily established.

The first case is described by Dr. Fitz " as one of
myxcedema in which marked and persistent albumosuria was
a feature. The patient died while under thyroid therapy.
Inasmuch as no autopsy was held, the case is not above
criticism. It is in the course of this publication that brief
reference is made to the only recorded American observa-
tion on multiple myeloma and albumosuria.

Askanazy's case of lymphatic leukemia " constitutes the
second apparent exception.

His patient was a man fifty-one years of age, who was ad-

'Med. Chlr. Trans., London, 18.50, vol. 3.3, p. 211.

* Loc. cit.

sPrag. Med. Woclienschr., 1889, Bd. 14, 8. 33.

'«Deut. Zeitschr. f. Chir., 1873, Bd. 3, S. 163.

" VIII Congresso dl medicina interna, 1897, (Transactions).

'■'Tiie cases reported are tbose of Bence Jones, loc. cit.; Kiihne and
Stokvis, loc. cit.; Kahler, loc. cit.; Stokvis, quoted by Rosin ; Seegelken,
Deut. Arch. f. Kl. Med., 1897, Bd. 58, S. 126; Rosin, Bcrl. Kl. Wochen-
schr., 1897, Bd. 34, S. 1044; Bozzolo, loc. cit.; Ewald, Wien. Kl.
Wochenschr., 1897, S. 169; Bradsl\aw, Med. Chir. Trans., London, 1899,
p. 2.51; Fitz, Amcr. Jour, Med. Sc, 1898, vol. 116, p. 30; Naunyn,
Deut. Med. Wochenschr., 1898, Vereins Beilage, S. 217; Ellinger, Deut.
Arch. f. Kl. Med., 1899, Bd. 62, S. 25.5; Sternberg, Nothnagel's Spec.
Path. u. Ther., 1899, Bd. vii, Tb. ii, Abth. ii, S. .57.

"Loc. cit.

"Deut. Arch. f. Kl. Med., 1900, Bd. 68, S. 34.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

mitted to the hospital iu June, 1898. In the summer of
1897 he began to complain of feeling weak; he lost weight
and was easily fatigued. Six months later he noted that the
cervical glands were enlarging. On admission he was some-
what anfemic; the legs and the abdominal wall were
cedematous. There was a moderate enlargement of the
lymph glands of the neck and axilte; several small subcu-
taneous glands were palpable over the chest wall. A gland-
ular tumor about the size of a man's head occupied the
right upper quadrant of the abdomen. Small tumors were
felt in Douglas's fossa. The blood showed the changes of
lymphatic leukaemia. The urine exhibited Bence Jones"
albumosuria. Five weeks later the patient died, and acute
pulmonary cedema being the immediate cause of death. At
the autopsy the ribs wei-e found very thin; four of them
were fractured presumably in transporting the cadaver.
A thick, gelatinous marrow, the color of meat, occupied the
wide meshes of the bony structure. Microscopically, this
marrow was composed of colorless elements, among which
the lymphoid cells predominated. There was a hyperplasia
of all the lymphatic glands.

Unless the process is to be viewed as a diffuse myeloma,
here is an exception. Until the relations of the myelomata
to leukaemic and pseudo-leuksemic processes are determined,
Askauazy's case must be considered one of lymphatic
leukaemia associated with Bence Jones' albumosuria. But
this single possible exception need not vitiate the import-
ance of albumosuria as a sign of boue-niarrow tumors, see-
ing that in all other instances where the investigation has
been thorough, a multiple myeloma has been the underlying
condition.

To demonstrate the converse proposition that aU cases of
multiple myeloma are accompanied by Bence Jones' albu-
mosuria is not possible, the data being insufiQcient. Several
considerations must be taken into account. The first is the
difficulty in deciding just what a myeloma is; a difficulty
to which I shall again refer. These urinary reactions seem
to be specific for myeloma, not an accompaniment of every
bone tumor. At the last German Congress for Internal
Medicine A'aunyn " stated that he had observed a patient
whose skeleton was riddled with metastatic carcinomatous
growths but the urine failed to give the reactions of Bence
Jones.

Furthermore, it must be borne in mind that the time of
the appearance of the reactions in the course of the disease
has not been definitely determined. In the Stokvis-Kiihne
ease the albumosuria appeared not until the illness was well
advanced and disappeared three months before death. But
this observation is exceptional ; the albumosuria is, as a rule,
an early sign and is persistent.

Quantitatively it is subject to great variations. In El-
linger's case the proteid content averaged from ^ to i per
cent, while in the famous specimen submitted to Bence
Jones, it reached the high percentage of six and nine-tenths.
Even in the course of any single ease there may be marked

" Verhand. d. Cong. f. inn. Med., 1900, S. 40R, et. spq.

remissions in the intensity of the reaction, a fact noted by
Matthes '' and likewise observed in the second case of our
series.

It must be shown, then, that the diagnosis of the nature of
the bone tumor has been well founded and that repeated
urinary examinations have been made before one can accept
V. Jaksch's statement that he has observed cases of multiple
myeloma in which there was not a trace of albumose in the
urine."

The exact nature of the substance giving rise to the reac-
tions of Bence Jones has not been determined. All investi-
gators have noted the close relation existing between these
reactions and tliose of the albunioses in Kiihne's sense, and
yet when isolated it differs in minor features from any of the
known digestive proteoses. Eecently before the German
Congress just referred to, Magnus-Levy "' denied its albu-
mose character. He stated that he had isolated Bence
Jones' proteid in crystalline form; that its property of being
dissolved at the boiling-point was not constant; that by the
addition of small quantities of salts or extractives such as
urea or by slight alterations in the physical conditions its
solubility or insolubility at a temperature of 100 degrees
could be brought about at will. Moreover, he argued, its
structure must be more complex than the albumoses, for as
a result of its peptic digestion almost all of the primary
split products, namely, the albumoses, were obtained.

The origin of the proteid is as obscure as its character.
Ellinger's attempt to extract it from the marrow tumors
was not successful. But his demonstration of its presence
in the blood is fairly satisfactory. On the other hand, in
his case of hmiphatic leukapmia Askanazy could not demon-
strate the reactions in the blood, yet was successful in find-
ing the proteid in an extract of the bone-marrow. You will
see that these are obscure problems requiring further re-
search.

Aside from the reactions to which I have so often
referred, there are no constant alterations in the urine.
Kahler"s patient voided 2,230 cc. in 24 hours, but he was
accustomed to drink large quantities of alkaline water.
Other^\'ise there is no reference to a polyuria comparable to
that exhibited by Dr. Igleharfs patient.

Bradshaw's patient voided a milky urine from time to
time for a jenT previous to the onset of any localizing
symptoms.

Besides the peculiar albuminose proteid the urine usually
contains albumin in traces. In Senator's case " there was a
coexisting nephritis manifesting itself by the presence in
the urine of numerous casts and albumin. At the autopsy
the kidneys were large and had suffered fatty and amj'loid
degenerations. Needless to add that a myeloma was also
disclosed.

I pass now to a more accurate description of the nature of
myelomata. Multiple new growths of the bone-marrow,
they do not correspond to the tisual conception of malignant

'5 Loc. eit.

IS See Rosin, loc. cit.

" Loc. cit.

February, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

neoplasms in the Cohnheim sense, inasmuch as they probably
never metastasize.

The name " multiple myeloma " originated with v.
Eustizky,'" who viewed the process as a simple hypertrophy
of the bone-marrow, and for these reasons : the tumors were
present only in the bones and, indeed, originated only in
the bone-marrow, that although multiple, they did not
metastasize; therefore, did not belong to the class of malig-
nant neoplasms. Since v. Rustizky's publication there have
been several attempts to gather together the scattered
records of apparently similar growths.'" Thus there have
been collected examples of diseases of the bone with most
diverse titles— osteomalacia, medullary pseudo-leuktemia,
sarcomatous osteitis, malignant osteomyelitis, lymphosar-
coma. Histologically in the majority of instances the struc-
ture has been that of a round-cell sarcoma. Eecently,
Wright ''' has described a myeloma in detail in connection
witli Fitz's case. The tumor elements, according to his re-
search, really form a variety of plasma cells. A myeloma
does not originate in the marrow cells as a whole, but in
only one of its elements, the plasma cell. Following the
results of this important contribution, the tumor may be
classed as a plasmoma.

In gross, these tumors form masses of soft reddish tissue
of various sizes, often ill-defined, replacing the normal
marrow and osseous substance. The sternum, ribs, ver-
tebra? and skull are prone to the affection though all the
bone may be involved. The tumors may or may not appear
on the exterior. The bones are softened and apt to suffer
pathological fractures with resulting deformities. These
facts of pathological anatomy explain in part the varying
clinical pictures of multiple myeloma.

A disease of later life, it affects males more frequently
and runs its course as a rule within two years. Bozzolo's
patient lived four years after the onset of the iirst symp-
toms, while the physician under Kahler's care suffered eight
years before death relieved him. The recital of this history
makes a harrowing tale, but as it serves to illustrate one type
of the disease I shall present it in some detail:

Dr. Loos was in 1879 a well-developed man, 46 years of
age, of healthy appearance. In July of that year he was
suddenly seized with severe pain in the upper half of the
chest on the right side. A brother physician examined him
but could not detect any abnormality. In the course of a
week he felt entirely well. The following December, sud-
denly and without apparent cause, he had another similar
attack of intense pain. This time, however, it was dis-
tinctly localized in an exquisitely tender area over the third
right rib in front. But just as before, the pain soon disap-
peared. The urine at this period presented no abnormal
change.

During the year 1880 paroxysms of intense pain, referred

I'Loc. cit.

20 See Hammer, Virch. Arch., 137, S. 300.

'" Contributions to the Science of Med. dedicated to Dr. W. H. Welch.
The Johns Hoplcins Press, Baltimore, 1900.

to numerous ribs and other parts of the trunk as well aa to
the right patella, alternated with periods of comfort, during
which he could attend to his busy practice. Any unusual
muscular exertion, however, would call forth violent pain.

In March, 1881, following a slight contusion, an exceed-
ingly painful and tender area appeared over the fifth left
rib. A flat elevation could be outlined over the costal sur-
face, but in the course of a few weeks both pain and ele-
vation had disappeared only to recur later in other ribs and
bones. During the latter part of this year and for the first
time, the urine gave a heavy precipitate with nitric acid.
The patient had lost considerable weight and looked ill.

The early months of 1882 were passed in much the usual
way. When confined to bed by the unbearable bone pain
and neuralgias his condition was truly pitiful. Every move-
ment aggravated and intensified his great suffering. Be-
sides, his nights were sleepless and paroxysms of tachy-
cardia and cardiac oppression added to his discomfort. The
summer of this year saw an improvement so that he was
able to resume to some extent his favorite pastime, hunting.
But the improvement was temporary, for before the year
closed the painful attacks returned, the anginal paroxysms
were renewed and in addition he was troubled with nausea.
The poor doctor's suffering continued during the follow-
ing two years, 1883 and 188-±. What with the pain in the
ribs and sternum, the anginal attacks and nausea, pares-
thesias in the lower limbs, visceral pains and obstinate in-
somnia, his state had become deplorable.

In 1885 a kyphotic bowing of the upper thoracic vertebral
column was noted. In December of this year Kahler saw
him for the first time. He was then cachectic; his spinal
column presented a dorsal kyphosis. Standing, his face
pointed down; the trunk appeared markedly shortened com-
pared with the length of the extremities. There was
marked tenderness on palpating certain circumscribed areas
over the body of the sternum and the ribs. Careful and re-
peated examinations of these regions disclosed very slight
elevations of the bony surfaces. The urine exhibited the
reactions of albumosuria.

The doctor's condition grew progressively worse in 1886.
Pain recurred in various bones of the trunk and neuralgias
in the nerves of the extremities. The kyphosis increased, the
thorax became deformed, the sternum projecting forward
and the ribs appearing correspondingly bent. In 1887 the
inguinal glands were found enlarged. The sense of hearing
had been diminishing for several years, but now its impair-
ment was very marked. A double labyrinthine affection
was diagnosed. In April of this year a well-marked crep-
itus could be elicited over the third right rib by_ pressure
and by the respiratory movements. A tumor appeared in
the right supraspinous region.

Finally, deformed, deaf and suffering, the patient was re-
leased by death in August, 1887.

I have spoken of the clinical diagnosis in the case as well
as the anatomical examination. The essential features of
this type of the disease are the paroxysms of pain referred

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

to the bones, the great deformity of the skeleton of the
trunk, the cacliexia and the presence of Bence Jones' albu-
mosuria. These are the eases that have been mistaken for
osteomalacia, but in no example of true osteomalacia have
these urinary reactions been discovered, so that the albu-
mosuria suffices for differentiation."

The patient shown you to-night illustrates a second class.
Here the tumors are visible and there are pathological frac-
tures. In Bozzolo's patient the tumors appeared on the
arms, shoulders and ribs. A diagnostic difficulty arises in
deciding whether these timiors are metastases of a primary
growth latent in some distant organ or multiple primary
tumors of the bone. The albmnosuria not only answers
this question but at the same time determines the nature of
the new growth. In no instance of multiple metastatic
osseous tumors have Bence Jones' reactions been present
and the new growth has invariably been a myelogenous
sarcoma, a myeloma.

In a third division must be placed the cases of multiple
myeloma in which the bone symptoms and signs are vague
or even absent. To this class belongs the ease of Ellinger:

His patient was a man 45 years of age who was admitted
to Lichtheim"s clinic in October, 1897. For about six weeks
he had had, almost daily, chilly sensations, fever and sweats.
His appetite failed and he felt ill. He did Jiot complain of
pain in any part of the body.

The man was fairly well nourished and presented slight
jaundice and fever. The urine contained some albumin and
biliary pigments. The jaundice diminished but the fever
persisted; the patient grew weaker and paler. Four weeks
after admission Bence Jones' reactions were discovered in
the urine. Two weeks later the clinical picture was clearly
one of progressive anaemia with hemorrhagic sputum and
effusions into the subcutaneous tissue, the joints and serous
cavities. In a few days this condition led to the exitus
lethalis. Just before death it was noted that percussion over
the sternum was painful. No diagnosis was made. Post
mortem, a multiple myeloma was discovered.

In cases such as Ellinger's the progressive anaemia and its
concomitants occupy the attention of the observer, and, un-
less the significance of the albumosuria is recognized, a diag-
nosis is impossible.

A transition from this class of multiple myeloma to those
in which the bone lesions are evident is illustrated by Dr.
Iglehart's patient. Macintyre's case, which formed the
basis of Bence Jones' observations, belongs to this variety
of myeloma. Macintyre wrote that " the affection to which
it bore the nearest resemblance was a severe attack of lum-
bago or sciatica." But he adds it was evident " that suf-
fering so intense must have a deeper seat and more formid-
able cause than mere muscular or neuralgic rheumatism."
In discussing the diagnosis of maladies of the bone, he
remarks that their nature is usually, not suspected until
they are fully developed and until deformities or fractures
are present. He adds very wisely : " It is this considera-

"See Kahler, loc. cit.

tion that, in my mind, invests the properties of the urine,
voided by this patient, with their chiefest interest."

In relating the clinical histories of multiple myelomata,
I have mentioned several of the anomalous symptoms — fever,
nausea, attacks of visceral pain, neuralgias and pares-
thesias.

The remarkable nervous symptoms have been considered
in detail by Senator. "" His patient presented a double hypo-
glossal paralysis, anaesthesia in the region supplied by the
third division of the trigeminal nerve and a paresis of the
arytenoideus. These curious phenomena so dominated the
clinical aspect of the case that in spite of the presence of
albumosuria a diagnosis was not reached. The autopsy dis-
closed myelomata, but no appreciable change in the nervous
sj'stem was found. Senator regards the ansmia in such
cases as the etiological factor, basing his opinion on the re-
searches which have demonstrated that not only slight
functional disturbances in the nervous system but even
gross alterations in its structure may occur in the course
of a profound auasmia.

I have attempted to show you how manifold is the symp-
tomatology of multiple myeloma. You may readily imagine
the obscurity of the cases in which the osseous system pre-
sents no localizing symptoms.

It is as a contribution to the diagnosis of these obscure
cases of a pernicious bone disease that I have presented this
preliminary report and emphasized the importance of Bence
Jones' nllmmosuria.

Discussion.

De. Welch. — The most interesting recent contribution to
the pathological anatomy of so-called multiple myelomata is
the paper of Dr. James H. Wright, to which Dr. Hamburger
has referred. It seems clear that the lesions of the bones in
this disease are not genuine tumors in the Cohnheim sense,
and that the multiple nodules are not to be regarded as
metastatic tumors secondary to a primary one. The growths
in the bones have much in common with the infectious
tumors. In the case reported clinically by Dr. Fitz and
anatomically by Dr. Wright, the tumor-cells were predomi-
nantly plasma cells. It remains for future investigations to
determine whether in all cases these multiple myelomata,
which, as well known, have been described under a great
variety of names, present the special histological characters
so well described by Dr. Wright. If so, they would belong
to the class of new growths, first designated by Unua as
plasmomata. To this class belong many of the so-called
infectious grauulomata.

I have recently examined a small tumor of the palpebral
conjunctiva sent to me for diagnosis and have found that
the tumor is composed almost whoUj' of plasma cells, mixed
with so few ordinary lymphoid cells that transitions between
the latter and plasma cells are not easy to find. Probably
some of the tutnors which we formerly were accustomed to

»3Berl. Kl. Wochenscbr., 1899, Bd. 36, S. 161.

Febhuaey, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

diagnose as l3aiipho-sarcoma, round-celled sarcoma, etc., will
be found to be plasmomata.

De. Atkinson. — Have these cases of albumosuria with
bone lesions any connection with the cases of osteitis de-
formans reported some years ago by Paget and recently by
Smith (Ergebnisse der AUgemeinen Pathologic und Patho-
logischeu Anatomie des Menschen und der Thiere); the dis-
ease coming on insidiously with enlargement of the bones,
gradual increase in the size of the head and shortening of the
body through degeneration of the bones and bowing of the
legs? In a certain number of those cases of osteoporosis

and osteosclerosis the end has been cancer of the bones,
and I suspect albumosuria might have been found if looked
for. I saw last spring an individual with typical osteitis
deformans but he showed no lumps on the bones and no such
reaction in the urine.

Dk. Hamburger. — I know of no relation between the two
conditions and of no literature on the subject.

Note.— The colored woman died February 1, 1901. Post mortem^
myelomata were found in the skull, left scapula, both clavicles, the
sternum, the right ilium and neck of the right femur.

Examination of Dr. Iglehart's patient now shows a slight but definite
elevation over the ninth left rib in front.

RErORT OF A CASE OF FULMINATING HEMORRHAGIC INFECTION DUE TO AN ORGANISM

OF THE BACILLUS MUCOSUS CARSULATUS GROUP.

By Gkorge Blumer, M. D., and Arthur T. Laird, M. D.

(From the Bcmhr Hijijknic Laboratory, Alhaiitj, N. Y.)

The subject of hemorrhagic infection in man, due to
organisms of the Bacillus mucosus capsulatus group, has
been so recently discussed in this country by Howard ' that
it seems hardly necessary to more than briefly review the
subject in reporting a new ease. The cases hitherto re-
ported have varied from one another to a considerable de-
gree in their intensity, and to a certain extent in the char-
acter of their lesions. Whilst in some cases the lesions
were purely septicemic and the infection of the cryptogenic
type, in other instances the process seems to have started
as a local infection, though quickly becoming generalized.
Thus the cases of Bordoni-Ulfreduzzi," Von Dungern' and
Kolb * were of the character of general infections without
special points of origin, the cases of Tizzoni and Giovanni '
seemingly originated from the skin, those of Babes ° from
the bronchi, and in our own case the intestinal tract was in
all probability the primary seat of infection. In all instances
the essential feature of the process was its hemorrhagic
character.

The following ease occurred in the practice of Dr. D. L.
Kathan of Schenectady, to whom we are indebted for the
history, and who kindly obtained permission for the autopsy.
The case seems worthy of record on account of the relative
rarity of this form of disease.

A. F., aged 20, a machinist.

Family Histonj. — His father died of cancer of the kidney
at 55. His mother died of pulmonary tuberculosis at 30.
Two sisters are alive and well. There are none dead in the
family.

1 Howard : .Journal of Experimental Medicine, vol. iv. No. a, 1899.

'Bordoni-Ua'reduzzi: Zeitsehrift fiir Hygiene, 1888, Hft. iii.

3 Von Dungern: Centralblatt fiir Bakteriologie, Bd. xiv, No, 17, 1893.

"Kolb: Arbeiten aus den Kaiserliche Gesundheitsamte, Bd. vii, 1891.

5 Tizzoni and Giovanni: Ziegler's Beitriige, vi, p. 201, 1889.

6 Babes: Archives de Medecine Expcrimentale, tome v, 1890.

Past History. — The patient has always been unusually
strong and athletic. His habits are excellent.

Present History. — The patient had been in perfect health
and working every day until October 19, 1900. On the
morning of that day he went to work as usual after a hearty
breakfast. He returned just after noon, not having eaten
his dinner. He complained of feeling ill, and went directly
to bed. He began to vomit and purge, the bowels moving
every few minutes. He complained of pain in the abdomen.
Examination showed that there was no local abdominal ten-
derness, no tympanites. The temperature was 103° F. The
pulse was 120.

At the end of twelve hours he was seen again. At that
time the bowels were only moving about once in four hours,
and the vomiting had practically ceased. The temperature
was subnormal. The hands and feet were cold and cyanosed.
The face had a pinched appearance.

At the end of 24 hours there was confusion of mind, and
the patient was in a state of complete collapse. Death oc-
curred at the end of 36 hours, there having been at no time
the slightest tendency towards recovery.

The autopsy was made six and a half hours after death in
cool weather.

The following notes are abstracted from the protocol:

The body is 171 cm. long, powerfully built, and well nour-
ished. Eigor mortis is well marked. There is extensive
post-mortem lividity of the legs, arms and trunk. The
surface is pale; there is no oedema. The lips and finger-tips
are cyanotic. The mucous membranes are pale. The mus-
cles are exceptionally well developed and normal looking.
The peritoneal cavity is dry, both layers of the peritoneum
being smooth. The omentum and appendix are normal.

The heart is in every way normal except for the presence
of numerous subepicardial hemorrhages of small size, and
slight cloudy swelling of the musculature.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

The lungs show numerous subpleural hemorrhages with
congestion, and a few elevated, finely granular, deep-red
areas, suggesting fresh broncho-pneumonia.

The spleen is much enlarged, measuring 16 X 10.5 X 5
em. On section it shows numerous hemorrhages into the
pulp, and marked swelling of the Malpighian bodies.

The liver is enlarged, soft, and markedly cloudy.

The kidneys both present the same appearances, being
much softer than normal, with their cortices pale and
swollen. There are a few submucous hemorrhages beneath
the mucous membrane of the pelves.

The adrenals, bladder, prostate and pancreas are normal.

The stomach shows a few submucous hemorrhages, but is
otherwise normal.

The solitary follicles throughout the small intestine are
markedly swollen, and in the ileum Payer's patches are also
affected. The mucosa of the intestine between the swollen
lymphatic apparatus is congested and in places markedly
hemorrhagic; in places the Peyer's patches contain discrete
hemorrhages.

The large intestine is normal.

The mesenteric glands are swollen, some of them being
pale, others hemorrhagic.

The brain and cord could not be examined.

MiCEOscopic Examination.

The heart-muscle shows uothiug beyond an excessive num-
ber of polymorphonuclear leucocytes in the vessels.

The lung shows in places groups of alveoli containing red
blood-corpuscles, with a few desquamated epithelial cells
and an occasional dust cell. The blood-vessels in this organ
also contain an excessive number of polymorphonuclear
leucocytes.

The liver shows marked cloudy swelling of its cells, with
occasional single-cell necroses. The portal vessels contain
a great excess of leucocytes, which have wandered out in
quite large numbers into the periportal connective tissue.

The spleen shows great dilatation of all its blood-spaces
with blood. In the pulp spaces many large phagocytic cells
containing red corpuscles are made out. There is no dis-
tinct evidence of proliferation of the endothelial cells lining
the splenic vessels.

The kidneys show marked cloudy swelling of the paren-
chymatous cells. The capillaries, especially those of the
glomeruli, are crowded with polymorphonuclear leucocytes.
Two distinct types of localized lesions are to be made out
in these organs. In places in the cortex are localized collec-
tions of polymorphonuclear leucocytes invading the tubules
and the intertubular connective tissue. In the medulla
near its junction with the cortex are areas in which the inter-
tubular connective tissue is quite oedematous-looking, and
is infiltrated with a few polymorphonuclear leueoeyteB, and
a moderate number of cells with round extracentral nuclei
which have the staining reactions of plasma cells. These
cells evidently come from the neighboring blood-vessels

which contain many of them. No casts are seen in the
tubules.

The changes iu the intestines are partly inHammatory and
partly proliferative iu character. The inflammatory changes
are most marked in the interglandular tissue and consist in
an infiltration with polymorphonuclear leucocytes accom-
panied by hemorrhage. The proliferative changes are most
marked in the lymphatic apparatus. They consist in the
appearance of large cells of an endothelial type amongst the
lymphoid cells which are greatly decreased in number.
These large cells have distinct phagocytic properties and
contain in places deeply stained particles of nuclear sub-
stance, presumably portions of lymphoid-cell nuclei. The
blood-vessels in and near the lymphatic apparatus show pro-
liferative changes in their endothelium. The proliferated
cells almost block the capillaries in places, whilst in other
places fibrin-formation with complete thrombosis has oc-
curred. The changes resemble in every way those described
by Mallory in typhoid fever, though less in degree.

The changes in the mesenteric lymph glands are essen-
tially the same as those in the lymphatic apparatus of the
intestine.

Sections of the various organs examined for microorgan-
isms show short thick bacilli in the blood-vessels of the lung
and in the areas containing exudate. They are also found in
the sections of intestine and in the mesenteric glands. The
organisms are, as a rule, free between the cells, but occa-
sionally are found in large numbers in polymorphonuclear
leucocytes. These organisms resemble those subsequently
isolated from the mesenteric glands and the lung.

Cultures were made at the time of the autopsy from the
heart's blood, lung, liver, spleen, bile and a mesenteric
lymph gland.

All of these remained sterile after several days in the
thermostat at C. 37°, except the culture from the lung,
and that from the mesenteric gland. The tubes from each
of these organs showed numerous colonies of a single organ-
ism which presented the following morphological and cul-
tural characteristics. Unless otherwise stated, cultures were
made on standardized media with an acidity of 1.5 accord-
ing to Whipple's scale:

Morphology. — In young cultures grown at the temperature
of the thermostat the organism appears as a bacillus, vary-
ing from 1 to 4 microns in length and averaging 0.5 micron
in width. The organisms occur singly or in pairs or chains
of 2 or 3 elements. The ends are rounded, many of the
short forms appearing almost oval. Occasional thread-like
forms are observed. Irregularly shaped forms, which stain
unevenly, are seen in old potato cultures (6 days at C. 36-
38°). The organism stains well with aqueous methylene
blue (1 :9), better with Loffler's methylene blue. Bipolar
staining is sometimes noticed in the short forms. The
organism is decolorized by Gram's method.

A capsule is to be made out by Welch's method in smears
from animal tissues, and is occasionally seen in blood-serum
cultures; it is not uniformly present.

February, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

No spore-formation is observed.

Flagella are not present, and the organism seems to be
non-motile.

The organism grows best aerobically, but is also capable
of growth under anaerobic conditions. It grows on media
as follows :

Agar Slant. — After 24 hours there is a luxuriant, elevated,
porcelain-white growth along the line of inoculation; the
edge is tinely serrated. There is abundant growth in the
water of condensation. The growth is not markedly viscid.
It has no odor.

Agar Plates. — The superficial colonies are circular, ele-
vated, about 2 mm. in diameter with a sharply defined mar-
gin and a snow-white color. Under the low power they are
made up of a coarsely granular periphery surrounding an
opaque center. The deep colonies are spherical or lens-
shaped, white, about 0.5 mm. in diameter, and microscopic-
ally finely granular in structure.

Gelatin Plates. — The surface colonies are small, not more
than 1 mm. in diameter; they show little tendency to spread
and are circular, elevated, white, and denser at the center
than at the periphery. Under the low power they arc yel-
lowish, coarsely granular, and show a concentric arrangement
and finely serrated edges. The deep colonies are spherical,
opaque and finely granular.

Gelatin Stah. — There is a delicate growth along the line
of the stab, and a slight circular non-elevated growth on the
- surface. No liquefaction is produced.

Potato. — After 24 hours there is a luxuriant, spreading,
moist, elevated, brownish-yellow growth. The potato is
discolored a brownish yellow. There is no gas production.

Dunham. — Is imiformly cloudy after 24 hours. No pel-
licle is formed. Later there is an abundant grayish-white
sediment, which on agitation diffuses evenly through the
liquid, and is not stringy.

Blood-serum. — The growth is similar to that on agar.
There is no liquefaction of the medium.

Indol-Formation. — The organism produces indol in dex-
trose free bouillon after 4 days at C. 37°.

Gas-Formation. — Several different tests were made with
each medium. Gas noted after 72 hours at C. 37°.

In 1 per cent glucose bouillon, 45-60 per cent of gas.

H f

In 1 per cent lactose bouillon, 45-55 per cent of gas.

H f

In 1 per cent saccharose bouillon, no gas is found as a
rule. On one occasion a trace was noticed.

Pathogenesis.— 25 minims of a 72-hour bouillon culture
were injected subcutaneously into the abdominal wall of a
full-grown guinea-pig. The animal died within 24 hours.
The autopsy showed slight swelling at the point of inocula-
tion, swelling of the nearest lymph glands with hemorrhages,
an early serofibrinous peritonitis, and hemorrhages into the
kidneys and beneath the pleura. The intestinal lymphatic

apparatus was swollen and surrounded by congested mucous
membrane. The organism was found in coverslips from the
point of inoculation and the blood, at times encapsulated. It
was recovered in pure culture from the seat of inoculation,
blood and spleen.

25 minims of a 72-hour bouillon cultui'e were inoculated
into the peritoneal cavity of a full-grown guinea-pig. The
animal died within 24 hours. The autopsy showed that
there was no local or glandular reaction. There was a dis-
tinctly viscid seropurulent peritoneal exudate. The spleen
was enlarged. There were hemorrhages into the adrenals
and beneath the pleura. There was a fresh right-sided
pleurisy. The organism was seen in the smears from the
blood and peritoneal cavity, many of the organisms from the
latter place having a distinct capsule. It was recovered in
pure culture from the heart's blood, spleen and peritoneal
exudate.

A full-grown rabbit was inoculated into the ear-vein with
25 minims of a 72-hour bouillon culture. It died within 20
hours. The autopsy showed no reaction at the point of in-
oculation. There was a fresh fibrinous peritonitis. The
spleen was enlarged, soft and congested. The liver and
kidneys were also congested, as was the mucous membrane
of the uterus. The organism was recovered from the heart's
blood, spleen and peritoneum in pure culture.

Anatomical Diagnosis. — Hemorrhagic infection due to an
organism of the Bacillus mucosus capsulatus growth; acute
hemorrhagic follicular enteritis; acute spleen tumor with
swelling of the Malpighian bodies; cloudy swelling of the
liver and heart muscle; acute infectious and interstitial
nephritis; hypostatic congestion of the lungs.

We have placed the organism isolated in this case in the
group of Bacillus mucosus capsulatus, since whilst it differs
in minor points from similar organisms already described, it
corresponds in the following features laid down by Fricke '
for the identification of members of this group. Howard,
quoting from Fricke, states as follows:

" The more important common characteristics of this
group are the morphology, plump, medium-sized, plemorphic
rods; the presence of capsules, readily demonstrable in the
animal body and sometimes in cultures; lack of motility and
of spores; failure as a rule to stain by Gram; the rapid,
luxuriant, elevated, viscid white growth upon the surface
of solid media; absence of liquefaction of gelatin; and
pathogenicity, usually in the form of septicaemia, but with
striking variations for difi^erent animals, and for different
members of the group."

In comparing this organism with a culture of Howard's
bacillus of hemorrhagic septicaemia which he kindly sent us,
and with a culture of Pfeiffer's capsulated bacillus, which
we obtained from the Laboratory of Hygiene of the Uni-
versity of Pennsylvania, the growth of the three organisms
on ordinary media was almost identical. Our organism,
however, failed to produce gas in saccharose bouillon, and

'Fricke: Zeitscbrift fiir Hygiene, Bd. xxiii, 1896.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

produced indol constantly. Both Pfeiffer's and Howard's
organisms produced abundant gas in saccharose bouillon.
We were never able to detect indol in cultures of Pfeiffer's
organism, though in one out of several cultures of Howard's
bacillus we obtained a faint indol reaction. Pfeiffer's organ-
ism was furthermore distinguished by the fact that on solid
culture media the growth constantly exhibited a mucilagi-
nous consistency so that it adhered to the needle and pulled
out into threads. In its failure to produce gas in saccharose
bouillon our organism seems to differ from all of the so far

recorded ones. The various organisms of this group studied
by Strong ° all produced gas in saccharose, as did the or-
ganisms recently studied by Howard."

The case is of interest pathologically on account of the
proliferative changes in the lymphatic apparatus of the in-
testine, and clinically on account of its exceedingly rapid
course.

8 Strong: Journal of the Boston Society of the Medical Sciences, vol.
iii, ISnSI.

' Iloward: Journal of Experimental Medicine, vol. v, no. 2, 1300.

INTRODUCTORY NOTE TO DRS. DURHAM AND MYERS'S REPORT.

The following short summary was sent to me by Dr. Dur-
ham with the suggestion that it appear in a medical journal
in this country. In justice both to the English Commission
and to the American Commission, it should be stated that
the comment in paragraph 11 is made without knowledge of
the later fuller experiments and important results recently
published by the latter commission.

Dr. Durham and Dr. Myers spent several days in Baltimore
last July on their way to Para, Brazil. All of us who met
these gifted young investigators retain the pleasantest re-
membrance of them personally and were impressed with their
fitness in scientific training and ability for the work which
they were about to undertake. A little over a month ago
came the sad news that Dr. Myers had succumbed to an
attack of yellow fever. Dr. Durham, who contracted the
disease at the same time, has fortunately recovered, and at
the date of his writing (January 29) was about to resume the
study of yellow fever.

The death of Dr. Myers at the outset of his career is a
severe loss to medical science. His published contributions
show thorough scientific training and marked originality,
and, although extending over a period of only about three
years, are valuable additions to knowledge, giving promise
of much fruitful activity as an investigator. They relate
mainly to problems of immunity, especially to immimity
from snake-venom and from proteids.

Both Lazear of the American and Myers of tlie English
Yellow Fever Commission have laid down their lives in the
search for means of prevention, based upon better knowledge
of the causation, of one of the most baffling and terrible
scourges of mankind. How much more glorious is the
cause to which these bright young lives were sacrificed than
any for which nations are in arms to-day!

WiLLi.vM H. Welch.

ABSTUCT OF INTERIM REPORT ON YELLOW FEVER BY THE YELLOW FEVER COMMISSION OF

THE LIVERPOOL SCHOOL OF TROPICAL MEDICINE.

By Herbert E. Durham and the late Walter Myers.

Note. — The completion of the interim report of which this is an
abstract was interrupted by the onset of attacks of yellow fever in
both of us. The loss of my much lamented colleague renders it advisa-
ble to submit this shortened report only for the time being. — H. E. D.

1. Sufficient search reveals the presence of a fine, small
bacillus in the organs of all fatal cases of yellow fever. We
have found it in each of the 14 cadavers examined for tlie
purpose. In diameter the bacillus somewhat recalls that of
the influenza bacillus; as seen in the tissues, it is about 4//. in
length.

2. This bacillus has been found in kidney, in spleen, in
mesenteric, portal and axillary ' lymphatic glands taken from
yellow-fever cadavers directly after death. In the contents
of the lower intestine apparently the same bacillus is found
often in extraordinary preponderance over other micro-

' We find these constantly enlarged and much injected, though whether
this is specific we are not able to say.

organisms. Preparations of the pieces of " mucus," which
are usually if not always present in yellow-fever stools, at
times may present almost the appearance of " pure culture."

3. Preparations of the organs usiuilly fail to show the
presence of any other bacteria, whose absence is confirmed
by the usual sterility of cultivation experiments.

4. It is probable that this same bacillus has been met with,
but not recognized, by three other observers. Dr. Stern-
berg (Eeport on Etiology and Prevention of Yellow Fever,
1890) has mentioned it, and he has also recorded the finding
of similar organisms in material derived from Drs. Domingos
Freire and Carmona y Valle, but he did not recognize its
presence frequently, probably on account of the employment
of insufficiently stringent staining technique.

5. It is probable that recognition has not been previously
accorded to this bacillus by reason of the difficulty with
which it takes up stains (especially methylene blue), and by

February, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

reason of the difficulty of establishing growths on artificial
media.

6. The most successful staining reagent is carbolic fuchsin
solution (Ziehl), diluted with 5 per cent phenol solution
(to prevent accidental contamination during the long stain-
ing period); immersion for several hours, followed by differ-
entiation in weak acetic acid. Two-hours staining period
may fail to reveal bacilli, which appear after 12 to 18 hours.
The bacilli in the stools are often of greater length than
those in the tissues, and they may stain rather more easily;
naturally the same is true of cultures. Some of our speci-
mens have already faded.

7. Since the bacilli are small and comparatively few in
numbers, they are difficult to find. To facilitate matters at
our last two autopsies (14th and 15th), a method of sedi-
mentation has been adopted. A considerable quantity of
organ juice is emulsified with antiseptic solutions, minute
precautions against contamination and for control being
taken; the emulsion is shaken from time to time and allowed
to settle. The method is successful and may form a ready
means of preserving bacteria-containing material for future
study. The best fluid for the purpose has yet to be worked
out; hitherto normal saline with about ^ per cent sublimate
has been employed.

8. Pure growths of these bacilli are not obtained in ordinary
aerobic and anaerobic culture tubes.

9. Some pure cultures have been obtained by placing
whole mesenteric glands (cut out by means of the thermo-
cautery) into broth under strict hydrogen atmosphere. In-

vestigation into the necessary constitution of culture media
for successful cultivation is in progress.

10. Much search was made for parasites of the nature of
protozoa. We conclude that yellow fever is not due to this
class of parasite. Our examinations were made on very fresh
organ jiiices, blood, etc., taken at various stages of the dis-
ease, with and without centrifugalization,'' and on specimens
fixed and stained in appropriate ways. We may add that
we have sometimes examined the organs in the fresh state
under the microscope within half an hour after death.

11. The endeavor to prove a man-to-man transference of
yellow fever by means of a particular kind of gnat by the
recent American Commission is hardly intelligible for a bacil-
lary disease. Moreover, it does not seem to be borne out
by their experiments nor does it appear to satisfy certain
endemiological conditions. It is proposed to deal more fully
with the endemiology and epidemiology of the disease on a
later occasion.

12. We think that the evidence in favor of the etiological
importance of the fine small bacillus is stronger than any
that has yet been adduced for any other pretended " yellow-
fever germ." At the same time there is much further work
to be done ere its final establishment can be claimed. The
acquisition of a new bacterial intestinal inhabitant would
explain the immimity of the " acclimatised."

Para, Brazil, Januarv 28, 1901.

'We have found this sometimes useful in examining the blood of
ague patients.

SUMMARIES OR TITLES OF PAPERS BY MEMBERS OF THE HOSPITAL AND MEDICAL SCHOOL
STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.

Irving P. Lyon, M. D. Types of Normal and Morbid
Blood. — Pai'k's Surgery by America7i Authors, Second
Edition, 1899.

Colored blood-plate showing types of normal and pathological blood,
with description.

Guy L. Hunner, M. D., and Irving P. Lyon, M. D. Men-
suration and Capacity of the Female Bladder. Obser-
vations on the female bladder dilated by atmospheric
pressure in the knee-breast posture. — The Journal of
the American Medical Association, December 16, 1899.

(This article is not identical with the article of the same title which
appeared in the Bulletin in December, 18!I9. It is a longer and fuller
article, from which the other was abridged.)

Irving P. Ly'on, M. I). On Peculiar Condition of the Hair.
— The Journal of Tropical Medicine, August, 1900.
[On Plica Polonica.]

Charles Gary, M. D., and Irving P. Lyon, M. D. Primary
Echinococcus Cysts of the Pleura. Eeport of a case of
primary exogenous echinococcus cysts of the pleura,
showing hyaline degeneration of the cuticle without
lamellation, with notes from the literature. — Transac-
tions of the Association of American Physicians, Wash-
ington, Vol. XV, 1900, and American Journal of the
Medical Sciences, October, 1900.

Irving P. Lyon, M. D., and Alfred B. Wright, Stud. Med.
An Inquiry into the Existence of Autochthonous Malaria
in Buffalo and its Environs. Preliminary report on
species of mosquitoes and blood-examinations. — Buffalo
Medical Journal, November, 1900.

THE JOHXS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice, abstracts of papers read, and other proceedings
of the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of
the Hospital. It is issued monthly.

Volume XI is complete with the present number. The subscription price is $1.00 per year. The set of eleven volumes will

be sold for $22.00.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

XOTES Oiy IVEU BOOKS.

Disinfection and Disinfectants. A treatise upon the best
known disinfectants, their use in the destruction of disease
germs, with special instruction for their application in the
commonly recognized infectious and contagious diseases.
By H. M. Bracken, M. D., Minnesota State Board of Health.
(Chicago, Illinois: The Trade Periodical Company, 1900.)

This little volume is most valuable. It is a manual con-
taining careful and specific directions for the disinfection of
clothing, rooms, patients, dead bodies and discharges from the
bodies of the sick. It has a chapter vrith complete and varied
information concerning the more common infectious diseases.
Specific directions are also given for the proper isolation and
care of smallpox, yellow-fever, tuberculous and other patients
suffering from infectious diseases. There is no manual in
English which contains similar practical information.

Fractures. By Gael Beck, M. D., Visiting Surgeon to St.
Mark's Hospital and to the German Poliklinik — with 178
illustrations. (PMlad4ilphia: W. B. Saunders £ Co., 1900.)

In this volume of 335 pages the writer has attempted to deal
with the general subject of fractures considered mainly from
the standpoint of the Kontgen ray. In fact the volume is
dedicated to Professor Kontgen. The introductory chapter
deals wth the general properties of the X-rays and their
adaptability to certain varieties of fractures.

Part I deals with the classification, signs, diagnosis and
treatment of fractures in general, with some special reference
to the process of repair of fractures and disturbances in these
processes. In connection with the subject of compound frac-
tures the author discusses in some detail the general principles
of aseptic surgical technique; a few pages are also devoted to
the peculiarities of fractures in children.

Part II deals with fractures of special regions. Fractures of
the shoulder and upper extremity are discussed in considerable
detail, especial attention being devoted to fractures of the
elbow joint and Colle's fracture. Fracture of the pelvis and
lower extremity are also treated of in some detail. The writer
especiallj- advises the ambulatorj' treatment of fractures of
the neck of the femur, the leg being immobilized by a plaster
of Paris dressing extending from the foot to the pelvis.

A chapter is devoted to fractures of the bones of the trunk
and another to fractures of the skull. In the latter the differ-
ential diagnosis of injuries to the head is considered and the
technique of operation for fracture of the skull discussed.

The volume contains an appendix on the practical use of the
Rontgen rays, in which the general principles of X-ray photog-
raphy as well as the more desirable varieties of apparatus are
considered. Considerable attention is devoted to the technique
of X-ray photography.

The value of skiagraphy in the diagnosis of obscure lesions
of certain organs and viscera is considered, especial attention
being devoted to the diagnosis of biliary calculi. The appendix
closes with a brief chapter on the errors of skiagraphy.

The volume is by no means an exhaustive discussion of the
subject of fractures, and in matters of treatment leaves much
to be desired.

The illustrations are numerous and are for the most part
taken from skiagraphs, some of which are very good while
others are decidedly unsatisfactory. There is in places a de-
cided ambiguity as to the author's meaning, as for instance in
discussing fractures of the diaphysis of the femur the follow-
ing sentence occurs:

" Generally the lower fragment is rotated outward and pulled
upward and to the inner and outer side of the upper one."

There is also an evident attempt throughout the volume to

dispense with the time honored terminology of " ieal " and to
replace it with " ic." In this attempt there is, however, a
most decided inconsistency, for in the same sentence the
axithor uses in connection with the same noun the adjectives
" chemic " and " mechanical," and in another place the adjec-
tives anatomic and stirgical are used in the same sentence.

The Treatment of Fractures. By Charle.s Locke Scudder,
M. D., Surgeon to the Massachusetts General Hospital, Out-
Patient Department, etc., assisted by Frederic J. Cotton,
M. D. With 585 illustrations. (Philadelphia: W. B. Hau-nders,
925 Walnut St., 1900.)

A carefully prepared work upon a subject of such general
interest and importance should be most cordially welcomed
by the profession.

In this volume of 433 pages with 585 illustrations the author
has treated the subject in a careful and systematic fashion.
As he distinctly states in the preface, " the book is intended
to serve as a guide to the practitioner and student in the
treatment of fractures of bone." The work is by no means
an exhaustive discussion of the subject, but rather a clear,
concise statement of the most important facts connected with
each particular fracture together with a careful description
of at least one satisfactory method of treatment of each frac-
ture. A great effort toward simplicity in the treatment of
fractures is evident throughout the book.

Especially to be commended are the illustrations in which the
work abounds, and these are for the most part of a high degree
of excellence. The results of careful studies of fractures
with the X-rays are incorporated in many of the illustrations
and afford abundant evidence of the value of skiagraphy in
this department of surgery.

Chapters 1, 2 and 3 deal with fractures of the skull and
vertebrae, fractures of the inferior maxilla receiving especial
attention.

Chapters 4, 5 and 6 are devoted to fractures of the ribs,
sternum and pelvis, with a brief reference to the urinary com-
plications of fracture of the pelvis.

The next two chapters are devoted to fractures of the scap-
ula and clavicle, while in chapters 9, 10 and 11 fractures of the
arm and hand are carefully discussed, the portions devoted to
fractures of the neck of the humerus and Colle's fracture
being especially satisfactory.

Four chapters are devoted to fractures of the leg and foot,
and in them, as well as in other parts of the book, the author
illustrates the results of the treatment of fractures of the
different bones by statistics from the Massachusetts General
Hospital. The use of a general anaesthetic as an aid in the
diagnosis and proper reduction of fractures is strongly advised.

Thrombosis, embolism and sepsis as complications of frac-
tures are briefly discussed.

In considering gaseous phlegmon as a complication of frac-
tures, the author speaks of the bacillus of malignant oedema
as the causative agent and does not mention the bacillus
aerogenes capsulatus.

Especially to be encouraged is the introduction by the
author of the terms " closed " and " open " to replace the
terms " simple " and " compound " as applied to fractures.

A brief chapter is devoted to the anatomy of the epiphyses
and their importance in fractures.

A chapter written by Dr. Colman treats of the value of the
X-raj's in the diagnosis of fractures and briefly discusses the
sources of error and the dangers associated with the use of
the X-rays.

A short chapter is devoted to the emploj'ment of plaster of
Paris in the treatment of fractures and methods of prepara-
tion of plaster of Paris dressings are described.

Febhuary, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

The book closes «iih a cluiplt-r on the ambulatory treat-
ment of fractures with a brief description of the methods to
be emiJloyed and the results that have been obtained.

Altogether this book shows great care and thought in its
preparation, fulfils a decided need, and is one which can be
recommended to both the student and the practitioner; it
should receive the hearty endorsement of the profession.

A Text-Book of Pathology. By Alfred StEiN'GEL, M. D. Third

edition. Revised. (Philadelphia: 11". B. SaundtTS ct Co., 1900.)

In this edition the author holds to his original purpose of

supplying the clinician with a concise book on pathology, and
he has briefly outlined the main points of g'cueral and special
pathology within the limits of a text-book of moderate size.
On account of the condensation necessary in a work of this
kind, the book is hardly one that would be suitable for those
beginning the study of pathology. It is a store-house of facts
which are necessarily stated boldly and dogmatically. A
greater diffuseuess and amplitude of statement would add
much to its value for the use of students. The volume is
abundantly illustrated, and contains a full index which adds
much to its value as a book for readj- reference.

A Manual of the Diagnosis and Treatment of the Diseases of
the Eye. By Edwaed Jackson, A. M., M. D., Emeritus Pro-
fessor of Diseases of the Eye in the Philadelphia Poly-
clinic, with 178 illtistrations and 2 colored plates. {Phila-
delphia: W. B. Sumidms, 1900.)

The book is all that it purports to be — a manual for students
of ophthalmology and for the general practitioner of medicine
— and we believe it serves its purpose admirably. It seems par-
ticularly well adax^ted to the wants of medical students, con-
taining, as it does, such a distinct, clear-cut, conservative and
concise exposition of oiJhthalmologic subjects. The bibliog-
raphic appendix to each chapter, giving references to the best
articles published on the subject discussed therein, is a decid-
edly valuable feature of the book. It broadens the scope of
the work very considerably without interfering much with its
brevity.

To review each chapter in detail is unnecessary, indeed, the
well known reputation of the author is sufficient guarantee
of the character of the book and we heartily commend it to
both students and physicians.

H. O. R.

Panama and the Sierras: A Doctor's Wander Days. By G.
FiiANK Lydston, M. D. Illustrated from the author's origi-
nal i)hotographs. {Chicago: The Kii-fiiun Press, 1900.)

This little book of nearly 300 pages is written in an easy,
readable style, and contains much of special interest to the
physician, although not in any sense a medical book. The
writer has an excellent ability to describe what he sees, and
he sees almost everything which passes about him. In some
instances he is flippant, but he is always interesting. The
book contains an account of a journey for health made to
California by way of the Isthmus of Panama and the experi-
ences of the writer upon the Isthmus, in Mexico, and also in
California.

Dr. Lydston is a native of California, and in revisiting the
State he renewed his acquaintance with many towns in the
mining region with which he was familiar as a boy. The
account which he gives of the exhausted mines and deserted
mining settlements is most interesting. The illustrations are
good, but some of them .should have been spared a sensitive
and susceptible reader.

Rhinology, Laryngology and Otology, and their Significance in
General Medicine. By E. P. Eriedrich, M. D., Privatdocent
at the University of Leipzig. Authorized translation from
the German, edited by H. Holbbook Curtis, M. D., Consult-
ing Surgeon to the New York Nose and Throat llosijital
and to the Diphtheria and Scarlet Fever Hospitals. {Phila-
delphia: W. B. Hatmdcrs & Co., 1900.)

In these days of extreme specialization in medicine, when
many of the leaders in our profession are seriously considering
the problems arising from the rapid growth of specialism and
the tendency of specialists to ignore the interdex>endence of
abnormal conditions of the general health and of the special
organs, it is refresliing and encouraging to read such a book
as Priedrich's, in which the preface oiJens ^vith the statement
that, " there is (at present) a laudable tendency to tighten
the bonds that unite the daughters to the mother science."
However much honor is due the individual worker who devotes
his time and energy to the study of special parts of the body,
or special diseases, the ideal physician, whether sxJecialist or
not, is, unquestionably, he who combines with his special
knowledge a broad conception of general medicine. Rarely
does one meet with -a physician who unites these qualities in
his personality to such an admirable degree as does Dr. Fried-
rich.

Throughout the entire book, the one thing that impresses
the reader more than all others, i^erhaps, is that the author
not onlj' possesses a fairly comi^lete knowledge of the special-
ties under consideration but is able at all times to view the
conditions present from the standpoint of the general practi-
tioner; never for a moment losing sight of the most minute
detail in the constitutional disturbance.

The author's keen, conservative, impartial judgment in the
consideration of all debatable points also impresses the reader.
Evidence from all sides is set forth fairly and honestly weighed.
When the facts seem to warrant it, a decision on the merits
of the case is rendered but always in a spirit of full con-
servatism.

The first chapter is devoted to a very brief consideration of
the anatomical relations existing between -the nose, pharynx,
larynx and ears, both with regard to continuity of surface and
similarity of tissue structure, and to a study of the effects,
general and local, of diseases of the respiratory tract. The
sig-niticance of the upper air passages in the physiology of
breathing is given special attention, much emphasis being laid
upon the importance of the nose as the respiratory pathway.

Chapters 2, 3 and 4 deal with the alterations in the upper
;iir passages and ears, that may be met with in the course of
diseases of the circulatory and digestive systems and of the
blood.

Chronic constitutional diseases like rachitis, acromegaly,
diabetes and gout are considered in chapter 5. The conflicting
theories regarding the etiology of laryngeal spasm and its
connection with rachitis are reviewed and the conservative
opinion offered that " the most we can say is that spasm of
the glottis in children is the expression of an abnormal excita-
bility of all the respiratory muscles, and that it often occurs,
in association with tetanic symptoms, in rachitic subjects as
the result of digestive disturbances." No one can object to
tliat.

The next two chapters, devoted to the acute and clironic
infectious diseases, deserve special mention, but nothing like
a satisfactory review can be made in brief. Twenty-five pages
are given to tuberculosis alone and are well worth reading.
The important role played by measles, scarlatina, typhoid,
diphtheria and influenza in the causation of suppurative otitis
media is thoroughly discussed. In passing, we may mention
that the otitis in measles is attributed to the appearance in

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

the aural mucous membrane of lesions exactly like those seen
on the buccal and pharyngeal membranes, showing that it is
a part of the general symptom complex and not due to exten-
sion of infection through the Eustachian tubes, lu scarlatina
the extension theory is again cast aside and evidence adduced
to show that the aural complications are toxic in character;
a parallel being drawn with scarlatinal nephritis.

Syphilis naturally comes in for a large amount of space in
the chapter on the skin and sexual organs. The physiologic
and pathologic relations between the upper air passages,
especially the nose, and the organs of sex are considered and
Dr. Mackenzie's article given special reference.

The last chapter is given to nervous diseases, and an appen-
dix follows dealing with the cranial nerves and with the
sequelfE of otorrhoea, with reference principally to involvement
of the brain, meninges or sinuses.

The book is well printed on excellent paper and is creditable
to publisher, author and translator alike. It is not intended
for a text-book nor a treatise on special diseases or organs
but, as its title implies, is a link to bind the specialist and
general practitioner closer together. Its abundant references
constitute it a valuable index to the literature of the sulijects

treated.

H. O. E.

An American Text-book of Physiology. Edited by William H.
Howell, Ph. D., M. D. Second edition, revised. Vol. I.
(I'Mhidcliihia: W. li. Hauiulers d Co., 1000. Price, $:! net.)

Tlie " American Text-book of Physiology," the first volume of
the second edition of which has just appeared, differs in several
respects from the text-books of physiology in general use at
present. In the first place it is written by a number of men
who are investigators in physiology as well as teachers; many
of the experiments described and figures and curves reproduced
are from tlie writers' own researches. By the division of the
work among a number of contributors, the literature of physi-
ology has been examined tirst-hand and tlie results of the most
recent investigators incorporated; too many of the text-books
offered to students are mere compilations from older and larger
works. The fact that the contributors are themselves working
physiologists and have gone over the literature of their respec-
tive subjects in a critical manner gives the book a freshness and
interest seldom found in an elementary text-book. The objec-
tion that the treatment of a subject will probably lack uni-
formity when there are several authors does not seem to have
much weight as far as physiology is concerned; at least the
want of uniformity in the various sections of this text-book is
decidedly less noticeable than that found in most of the books
written by Individual authors. When the books of the latter
class are examined it is found that in almost every case some
part of the subject receives what most jjliysiologists consider
to be undue emphasis; the jiart thus treated varies according
to the subjects in which the various authors happen to be
chiefiy interested. In the present case the writers, having com-
paratively small fields of physiology to cover, have been able to
get a better grasp of their part in all its phases than is possible
for a man who has the entire subject of physiology to discuss.

The first edition of this text-book, w-hich was published four
years ago, appeared in the form of a single volume of over a
thousand pages; to many this volume seemed inconveniently
large, so that in the present edition the work has been divided
into two parts. In the first volume the physiology of the blood,
circulation, secretion, digestion, nutrition, respiration and ani-
mal heat and the chemistry of the body are considered. The
editor has written more than a third of this part, and it seems
to the reviewer that this writer's contributions are deserving of

special praise; they are characterized by great clearness and
accuracy of statement, and the most important points are kept
in the foreground while isolated details of minor importance are
avoided. In a brief introduction Professor Howell discusses the
more general problems of physiology and the composition and
general activities of living matter; then follow chapters by the
same author on blood and lymph. Before the intricate problem
of the formation of lymph is discussed a brief chapter on dif-
fusion and osmosis and other physical processes, discussed from
the standpoint of the newer phj'sical chemistry, is introduced.
The chapter on the mechanics of the circulation and the move-
ment of the lymph is written by Professor Curtis, while the
innervation of the heart and blood-vessels is discussed by Dr.
Porter. Porter also contributes a section on the nutrition of the
heart, a subject to the knowledge of which he and his pupils
have made such important additions. The chapters on secre-
tion, digestion and nutrition and the movements of the alimen-
tary canal, bladder and ureter are written by Howell; the most
noticeable feature of these chapters is the iiicorporation- of the
recent very valuable work of Pawlow on the relation of the
nervous system to the secretion of the digestive glands and the
full discussion of the subject of Internal secretion. Respiration
and animal heat are discussed by Professor Eeichert, one of
the few physiologists in this country who has had practical
experience with the calorimeter. The final chapter of the first
volume, on the chemistry of tlie animal body, is contributed
by Professor Lusk; the recent work of Fischer on the purin
bases and that of Kossel and his pupils on protamins are full}'
discussed.

In the second volume, which is to appear shortly, the physi-
ology of muscle and nerve, of the central nervous system, of the
sense organs and of reproduction will be discussed. The
arrang-cment of the sections has been altered somewhat in the
new edition; one change would seem to call for some comment.
In the former edition the physiology of muscle and nerve was
the subject first discussed; in the new edition this section is
jilaced in the second volume " so as to bi'ing it into its natural
relations with the Physiology of the Central Nervous System."
There are undoubtedly some advantages in this change, but it
is questionable whether they are not outweighed by certain
obvious disadvantages. With the present arrangement the
leader meets constant references to the physiology of striped,
plain and cardiac muscle, to nerve impulses, sympathetic nerve
fibres, etc., before these elementary terms are defined — a manner
of presenting the subject few teachers would care to adopt iji
their lectures.

On the whole this work is certainly the best text-lxxik of
physiology for medical students in the English language, and it
xvill doubtless continue to be used generally in all medical
schools of the first class. R. H.

Modern Medicine. By Julius L. Salingeh, M. D., and Frederick
J. Kalteyer, M. B., of Philadelphia. (PliihideJiiliin : W. B.
Saunders & Co., 1900.)

In this work of 800 pages the authors have endeavored to
combine the essentials of phj'sical diag-nosis, bacteriology and
clinical microscopy as applied to clinical medicine with the
general description of diseases as usually taken up in a text-
book of medicine. They state that " it has frequently been
necessary for the student to procure separate books upon these
topics." We hope that it will always be necessary for the
student to do so. It is certainly advisable. The man who is
studying medicine to-day and is not prepared to have a good
text-book of medicine in addition to works on phj'sical diagnosis
and clinical methods had better choose some other calling.

In the first 100 pages general symptomatology and semeiology

Febeuaet, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

are considered. This has necessarily been much condensed, but
the authors have made the best use of the space. Clinical bac-
teriology occupies 22 pages, and then about .50 pages are given
to laboratory methods. In the description of the methods of
examination of the stomach contents no mention is made of
Topfer's test for free hydrochloric acid, nor is the question of
ether extraction referred to in discussing Uffelmann's test for
lactic acid.

The g-reater part of the book is taken up with the discussion
of disease. Of necessity, the various diseases have to be con-
sidered briefly and only the most important points taken up.
In the discussion of epidemic cerebrospinal meningitis no men-
tion is made of lumbar puncture, our most valuable means of
diagnosis. The writers have evidently been fortunate in their
diagnosis of syphilis when they state that " it can scarcely be
confounded with any other disease." They probably mean that
the diagnosis of a typical case is easy, but it is such general
statements, which of necessity have to be made, that constitute
the great objection to books of this kind. There is something
of everything, but not enough of anything.

Transactions of the American Surgical Association. Vol. XVIII.
Edited by De Foeest Willard, JI. D., Ph. D., Recorder of the
Association. (PhiUidcliikUi : Win. ./. DuriKin, t'JdO. Cloth,
pp. 468. Illustrated.)

This volume of the Transactions of the Surgical Association
deals with subject.^ of much interest in modern surgerj' and the
papers on the whole are of a high degree of merit. The sjm-
posium on gastric surgery quite thoroughly covers the subject
of surgery of the stomach and contains papers of a g^eat deal
of value. The presidential address by Weir of New York em-
bodies the result of much personal experience in the treatment
of perforating lilcer of the duodenum and includes the abstracts
of 51 cases which have been reported up to the present time.
Rodman of Philadelphia discusses hemorrhage from non-per-
forating gastric ulcer in a thorough manner and has carefully
tabulated 40 cases which had been reported up to the time of
))ublication of his paper. Finney discusses perforating gastric
ulcer and tabulates the eases which have appeared during the
jiast few months, bringing the subject up to date. Benign ob-
struction of the pylorus is discussed by Kammerer of New York;
malignant disease of the stomach, by Mayo of Rochester,
Minnesota; the surgical treatment of dilatation of the stomach,
by Curtis of New York; the diagnosis of carcinoma of the
stomach, by Hemmeter of Baltimore; and the surgical treat-
ment of hourglass stomach, by Watson of Boston.

The volume also contains reports of some unusual and very
interesting cases, including a case of stricture of the oesophagus
following typhoid fever which was operated upon by gastrostomy
by Dennis of New York; nephrectomy for a large aneurysm of
the renal artery, by Keen; removal of acutely inflamed tuber-
culous mesenteric glands simulating' appendicitis, by Richard-
son, and also by Elliott of Boston.

The present interest in the operative treatment of peritoneal
infections In typhoid fever makes the paper by Warren report-
ing 27 eases of this kind of special interest.

The discussions on the various papers are given in full and
contain much that is almost as valuable as the papers, many of
which are among the most imiiortant contributions to the sub-
jects under consideration which have thus far appeared.

Atlas and Epitome of Diseases caused by Accidents. By Dr.
Ed. Golebiewski, of Berlin. Authorized translation from
the German with editorial notes and additions by Pearce
BAtLET, M. D., Consulting Neurologist to St. Luke's Hospital
and the Orthopedic Hospital, New York; Assistant in Neu-
rology, Columbia University. 40 colored plates and 100 illus-

trations in black, pp. .549. (rhiUidelphUt: W. B. Sauiulcrs d-

Co., 1900.) Price, $4.
This book undertakes to give a systematic description of the
sequels to injuries to all the organs of the body by accidents.
It is divided into two parts, one treating of injuries in general,
the other of injuries affecting the special structures and regions
of the body. The book contains reports of numerous cases of
injuries from various causes to illustrate the subjects under con-
sideration, and a large number of fine colored illustrations. It
is difficult to see the value of many of the illustrations, however.
For example, it hardly seems necessary to devote a whole page
cut to show the appearance of the scar resulting from a com-
pound fracture of the femur and ilium or to show the appear-
ance of the cicatrix following an operation in a case of strangu-
lated hernia. Most of the illustrations seem 1o be of about this
character. The text often seems very inadequate and inaccu-
rate; for example, under hernia, we are told that " the external
protrusion of any part of the intestine out of the abdominal
cavity or its escape into another body cavity is called a hernia,"
without any reference to the possibility of omental hernia, her-
nia of the bladder and of other organs. Very much of the text
will have little value for most physicians. The following is an
example: " Incised wounds are produced by pieces of glass, sharp
pieces of tin, by knives, saws, pieces of slate, etc. The greatest
possible variety of wounds of the forearm is met with in work-
men employed in the various trades and manufactures." Con-
siderable space is devoted to a cfiscussion of the length of time
usually required for recovery from various injuries, the amount
of loss of function and the allowance of insurance. Indeed, the
book seems to be designed chiefly for German readers, the need
of such a text-book arising from the law in Germany insuring
all workmen against injury. Although the book contains re-
ports of many interesting cases, we believe it will hardly jjrove
of great value to the average American reader.

Elements of Clinical Bacteriology for Physicians and Students.
By Drs. E. Levy and F. Ivlemperer. Second edition, trans-
lated by Dr. Aug. A. Esiinee. {PhiUiilelpliia : W. B. Kwiofi/fcs
d Co., WOO.)
This book, originally published in Germany and presented in
English to the profession and students of America in a clear
and comprehensible manner, is well classified and written, and
contains numerous illustrations of an excellent kind.

Compared with many books of like nature in use in this
country, it cannot be said to be their peer. And judged by the
most recent American standards, its presentation of many tech-
nical details is found in some degree to be lacking in accuracy
and compass. Nevertheless, a perusal of its pages will reveal,
interesting matter, such as the articles on botulism, the mycoses
and disinfection. N. ]\l.\cL. H.

Saunders Pocket Medical Formulary, with an Appendix contain-
ing posological table; formulte and doses for hypodermic
medication; poisons and their antidotes; diameters of the
fenuile pelvis and fnetal head: obstetrical table; diet list for
various diseases; materials and drugs used in antiseptic
surgery; treatment of asphyxia from drowning; surgical re-
membrancer; tables of incompatibles; eruptive fevers;
weights and measures, etc. By William 51. Powell. M. D.
Sixth edition, thoroughly revised. {PMladelphid : 11'. B.
gawi4ers <£■ Co., 1900.)
The object of this neatly printed and attractive book is so
well set forth in the title that little comment is necessary. It
does not seem so much a formulary as a remembrancer, and it
will be mainly useful as bringing to mind procedures and reme-
dies which in the strenuous life of the busy practitioner are
sometimes overlooked. It is well arranged for easy reference.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 119.

PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.

THE JOHNS HOPKINS HOSPITAL REPORTS.

Volume I. 423 pages, 99 plates.

Report in Pathology.

The Vessels and Wnlls of the Dor's Stomnch: A Study of the Intestinal
Contraction: Heallnpr of Intestinal Siitnres; Reversal of the Intestine;
The Contraction of the V-^na I'ortae and its Influence upon the Circu-
lation. By F. I". M.u.L, M. D.

A Coutrilnition to the I'athDlogy of the Gelatinous Type of Cerebellar
Sclerosis (Atrophy). By Henry J. Berklf.v. M. D.

Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By
F. r. Mall, M. D.

Report in Derinntolof^y.

Two Cases of Protozoan (Coccidioidal) Infection of the Sl;in and other
Organs. By T. C Gtlchrist. iM. D., and Emmkt Ri.xford, JI. P.

A Case of Blastomycetic Dermatitis in Man: Comparisons of the Two
Varieties of Protozoa, aud tlie Blastomyces found in the preceding
Cases, with the so-called Parasites found in Various Lesions of tiie
Skin, etc.: Two Cases of Molluscnm Fibrosum: Tlie Pathology of a Case
of Dermatitis Herpetiformis. (Duhring). By T. C. Gilchrist, M. D.
Report in Patliologry.

An Experimental Study of the Thyroid Gland of Dogs, with especial con-
sideration of Hypertrophy of this Gland. By W. S. Halsted, M. D.

Volume II. 570 pages, with 28 plates and figures.

Report in nieilicine.

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia asso-
ciated with Gallstones. By William Osler, M. D.

Some Remarks on Anomalies of tlie Uvula. By John N. Mackenzie, M. D.

On Pyrodin. By H. A. Lafleur, M. D.

Cases of I'ost-febrile lusanity. By William Osler, M. D.

Acute Tuberculosis in an Infant of Four Months. By Harrv Toulmin, M. D.

Rare Forms of Cardiac Thrombi. By William Osler, M. D.

Notes on Endocarditis in Phtiiisis. By William Osler, M. D.
Report in Sleilicine.

Tubercular I'eritonitis. By William Osler, M. D.

A Case of Raynaud's Disease. By H. ]\I. Thomas. M. D.

Acute Nephritis in Typlioid Fever. By William Osler, M. D.
Report in Gynecology.

The Gynecological Operating Room. By Howard A. Kelly, M, D.

The Laparotomies performed from October IG. 1.9S:>. to March 3, 1890. By
Howard A. Kelly. M. D., and Huster Uobb. M. D.

The Rejiort of the Autopsies in Two Ca.si's Dying in tlie Gynecological
Wards without Operation: Composite Temperature and Pulse Charts of
Forty Cases of Ahdominal Section. By Howard A. Kelly, M. D.

The Management of the Drainage Tube in Abdominal Section. By Hunter
RoBR, M. D.

The Gonococcus in Pyosalpinx: Tuberculosi.s of the Fallopian Tubes and
Peritoneum Ovarian Tumor: General Gynecological Operations from
October W, 1S89. to March 4. 1890. By Howard A. Kelly. JI. D.

Report of the Urinary Examination of Ninety-one Gynecological Cases. Bj
Howard A. Kelly, JI. D.. and Alrert A. Giihiskey, M. D.

Ligature of tlie Trunks of the Uterine and Ovarian Arteries as a Cleans of
Checking Hemorrhage from the Uterus, etc. By Howard A. Kelly. M.D.

Carcinoma of the Cervix Uteri In the Negress. By J. W. Williams, M. D.

Elephantiasis of the Clitoris. By Howard A. Kelly. M. D.

Myxo-Sarcoina of the Clitoris. By Hunter Roan JI. D.

Kolpo-Ureterotoniy. Incision of the Ureter through the Vagina, for the
treatment of Ureteral Stricture; Record of Deaths following Gyneco-
logical Operations. By Howard A. Kelly. M. D.
Report in Surgery, I.

The Treatment of Wounds with Especial Reference to the Value of the
Blood Clot in the Management of Dead Spaces. By W. S. Halsted, M.D.
Report in Neurology, I.

A Case of Chorea Insaniens. By Henry J. Berkley, M. D.

Acute Anglo-Neurotic Oedema. By Charles E. Simon, M. D.

Haematomyelia. By August Hoch, M. D.

A Case of Cerebro-Spinal Syphilis, with an uuusual Lesion in the Spinal
Cord. By Henry M. Thomas, M. D.

Report in Patliology, I,

Amoebic Dysentery. By William T. Councilman, M. D., and Henri A.
Lafleur. M. D.

Volume III. 766 pages, with 69 plates and figures.

Report in Patliology.

Papillomatous Tumors of the Ovary. By J. Wiiitridge Williams. M. D.

Tuberculosis of the Female Generative Organs. By J. Wiiitridge Williams,
^I- ^- Report in Patliology.

Multiple Lympho-Sarconiata, with a report of Two Cases. By Simon Flex-
NEIt. M. D.

The Cerebellar Cortex of the Dog. By Henry J. Berkley-, M. D.

A Case of Chronic Nephritis in a Cow. By W. T. Cou.nch.man, M. D.

Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.

Heart Hypertrophy. By Wm. T. Howard, .Ir., M. D.
Report in Gynecology.

The Gynecological Operating Room; An External Direct Itethod of Measur-
ing the Conjugata Vera: Prolajisus Uteri without Diverticulum and
with Anterior Enterocele: Lipoma of the Ijabiuiu Majiis; Deviations of
the Rectum and Sigmoid Flexnre associated with Constipation a Source
of Error in Gynecological Diagnosis; Operation for tlie Suspension of
the Retroflexed Uterus. By Howard A. Kelly, M. D.

Potassium Permanganate and Oxalic Acid as Germicides against tlie
Pyogenic Cocci. By ^Uky Sherwood, M. D.

Intestinal Worms as a Complication in Abdominal Surgery. By A. L.
Stavely. M. D.

Gynecological Operations not involving Coeliotomy. Bv Howard A. Kellt,
:M. D. Tabulated by A. L. Stavelt. M. D.

The Employment of an Artificial Retroposition of the Uterus In covering
Extensive Denuded Areas about the Pelvic Floor; Some Sources of
Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly,
M. D.

Photography applied to Surgery. By A. S. Murray.

Traumatic Atresia of the Vagina with Haematokolpos and Hieinatometra.

By Howard A. Kelly, M. D.
Urinalysis in Gynecology. By W. W. Russell. M. D.
Tho Importance of emp.'oying An.'esthesia in the Diagnosis of Intra-Pelvic

Gynecological Conditions. By Hunter Robb. M. D.
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.
One Hundred Cases of Ovariotomy performed on Women over Seventy

Years of Age. By Howard A. Kelly, ^I. D.. and Mart Sherwood, M. D.
Abdominal Operations performed in the Gvnecological Department, from

March !i. 1890, to December 17, 1892. By Howard A. Kelly, M. D.
Record of Deaths occurring in the Gynecological Department from June 6,

1890, to May 4, 1802.

Volume IV. 504 pages, 33 charts and illustrations.

Report on Typlioid Fever.

By William Oslee, JI. D.. with additional papers by W. S. Thayer, Jl. D.,
and J. Hewetson, M. D.

Report in Neurology.

Dementia Paralytica in the Negro Race; Studies in the Histology of the
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Intrinsic Nerves of the Submaxillary Gland of Mux musinlus: The
Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements
of the Pituitary Gland. By Henry J. Berkley, M. D.
Report in Surgery,
The Results of Onerations for the Cure of Cancer of the Breast, from
June, 1889, to January, 1894. By W. S. Halsted, M. D.
Report in Gynecology.
Hydrosalpinx, with a report of twenty-seven cases: Post-Operative Septic
Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
Report in Patliology.
Deciduoma Malignum. By J. Whituidge Willi.vms, M. D.

Volume V. 480 pages, with 32 charts and illustrations.

CONTENTS:
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewet-
son. M. D.
A Study of some Fatal Cases of Malaria. By Lewellvs F. Barker. JI. B.

Studies in Typlioid Fever.

By William Osler, ^I. D.. with aildilional papers by G. Blumer, M. D.,

Simon Flexner. JI. D., Walter Reed, M. D.. and H. C. Parsons. M. D.

Volume VI. 414 pages, with 79 plates and figures.

Report in Neurology.

Studies on the Lesions produced by the Action of Certain Poisons on the
Cortical Nerve Cell (Studies Nos. I to V). By Henry .7. Berkley, M. D.

Introductory.— Recent Literature on the Pathology of Diseases of the Brain
by the Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Exper-
imental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alco-
Iiol). 2. Experimental Lesions produced by Acute ,\lcoliolic Poisoning
(Ethyl Alcohol); Part II.— Serum Poisoning. -Experimental Lesions in-
duced by the Action of the Dog's Serum on the Cortical Nerve Cell;
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Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical
Nerve Cell produced by the Toxine of Experiiuental Rabies; Part V.—
Pathological Alteration's in the Nuclei and Nucleoli of Nerve Ceils from
the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal
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Report in Pathology.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By
Thomas S. Cullrn. M. B.

Pregnancy in a Rudimentary Uterine Horn. Rupture. Death, Probable
Jligration of Oviur. and Spermatozoa. By Thomas S. Cullen., M. B., and
G. L. WiLKiNs. :m. D.

Adeno-JIyoma Uteri Diffusum Benignnm. By Thomas S. Cullen, M. B.

A Bacte'rioiogicnl and Anatomical Study of the Summer Diarrhoeas of
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The Pathology' of Toxalbumin Intoxications. By Simon Flexner, M. D.

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V. The Results of Operations for the Cure of Inguinal Hernia. By
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Volume VIII. 553 pages with illustrations.

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Studies in Tyiilioid Fever.
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BULLETIN

THE JOHNS HOPKINS HOSPITAL

Vol. XII -No. 120.

BALTIMORE, MARCH, 1901.

[Price, 15 Cents.

CONTENTS.

PACK

The Genesis of Carciuoma cif tbe Fallopian Tube iu HyperpUistic
Salpingitis, witb Report of a Case and a Table of Twenty-one
Reported Cases. By E. R. Le Count, M. D., .5.5

Report upon a Case of Gonorrlia'al Endocarditis in a Patient Dyins;
iu the Puerperium ; with Kefereuce to two Recent Suspected
Cases. By Norman MacLeod Hakhis, M. B., and \Vm. M.
Dabney, iM. D., t!8

PAGE

An Experimental Study concerning the Relation which the Prostate
Gland Bears to the Fecundative Power of the Spermatic Fluid.
By Geohge Walkeu, M. D., 77

Summaries or Titles of Papers by Members of the Hospital and

Medical School Staff Appearing Elsewhere than in the Bulletin, 80

Further Observatious on Epincidirin. By .John .J. Ahel, M. D.,

THE GENESIS OF CARCINOMA OF THE FALLOPIAN TUBE IN HYPERPLASTIC SALPINGITIS,
WITH REPORT OF A CASE AND A TABLE OF TWENTY-ONE REPORTED CASES.

By E. K. Le Count, M. D.,
Assistant Professor of ralhology, Rush Medical CoUege.

{From t/ic Pul/iuldr/iral L'thiirndirij «/ Itnsh Medical College.)

Among theoretical conceptions of pathological processes
to which disease is attributable are certain ideas that have
at their inception the distinctness of a silhouette. Witli
the advancejiient of knowledge, the margins of certain no-
tions lose their definiteness and we find various processes
uniting insensibly at their boundaries. The idea that
necrosis means death of tissue remains firmly planted, but
the exact limitation of its import is considerably blurred
when the process of gradual death is screened behind tlie
caption of atrophy. Any attempt deserves approval that

has for its object the segregation and classification of morbid
processes that lie in the boundary zone. It seems, however,
that as time advances the narrow distance now separating
the process of tissue hyperplasia from that concerned in the
development of benign tumors will not be increased. Lu-
barsch,' after commenting on the close connection between
tumors and infectious processes, notes this difficulty in the
followins: words: " Suchte man daher nach anderen un-

Ergebnissed. alls;. Path. ii. path. Anat., 18!).5, ii, p. 'i90, Wiesbaden.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 120.

terschiedeiien Kriterien, so maclite sicli eine weitere
Sehwierigkeit, die Abgrenzung gegeiiiiber die Hyperplasie
bemerkbar." Still, it is evident that if a process of ques-
tionable character midway between tumor and hyperplasia
can be traced to an inflammatory origin, its position is no
longer in doubt. It must of necessity be considered as
hyperplasia or the meaning of the word tumor will require
modiiication. In lesions of such uncertain species, in which
the inflammatory origin is manifested by simply one of the
inflammatory phenomena, viz., that of proliferation, the
question seems surmountable in only one way — to admit
without further discussion the existence of a firm bond
uniting them. Such a solution of the problem is rendered
easy by finding lesions which represent all transition stages
from one process to .another. An example of this kind is
reported by W. W. Van Arsdale: ' a growth developed on the
upper right arm two days after several blows received during
a sparring bout. A fluctuating swelling that increased the
circumference of the arm 10 cm. was present two days aftei
injury; one month later the mass had decreased to one-third
its former size, but it had become hard and inunovable.
Two months after the injury, a growth 9 cm. in length and
3 cm. in its other diameters was chiseled from lietween the
biceps and branchialis anticus; it was found to jxissess an
outer shell of bone 1.5 cm. thick, the jieriosteuni l)eing
closely adherent to its e.\terior, and a cavity filled with dark
partially coagulated blood; its outer wall was true bone and
its cavity devoid of bone-nuirrow proper; its inner wall was
porous vascular bone.

It seems reasonably certain that In tiiis case the clot of a
subperiosteal haemorrhage became ossified at least in its outer
part. According to Klebs,'' the process of bone-formation
in this " Ossifying hajmatoma " would serve as an example
of hyperplasia; for, he states, the line between hyperplasia
and tumor-growth may be determined to some extent by the
preponderance of the former in scars and granulation tissue
and its proneness to spontaneously disappear. The growth
would be inflammatory in origin, for the unabsorbed blood
would excite an inflammation in the surrounding parts
(Cohnheim).* According to Lubarsch," the apparently au-
tonomous hyperplastic growths almost without exception
follow inflammatory excitants. Notwitlistanding these
opinions, it is unreasonable to suppose that had ossification
been allowed to continue throughout the entire coagulum,
that the mass of new bone would ever have disappeared spon-
taneously; there would have resulted an osteoma — a benign
tumor. Surgeons are well acquainted with the permanent
character of the bony hyperplasia which occurs in a luxu-
riant callus and the osteomas that develop in the biceps and
pectoral muscles from the kick of a gun (Tillmanns).

Another instance of lesions which represent transitions
between hyperplasia and benign tumor is furnished by mul-

5 Ann. Siirs., 1893, xviii, p. S, Phil.

3 Die allt;. Patliologie, etc., ii, p. 491, 1889, .Jena.

■• Vorlesungeu iiber allg. Pathologie, p. 393, 1882, Berl.

5L. c., p. 397.

tiple adenomata of the liver. In proof of their mediate po-
sition is the fact that equally good authorities are arranged
on opposite sides: Weichselbaum, Eindfleisch, Chiari and
Kretz classify the condition with simple hyperplasia; Lu-
barsch, Thoma, Poufick and Eppiuger with adenomata.
Orth '' seriously considers the question of tumors arising
from multiple nodular hyperplasia of the liver, and
Schmieden,' in a recent review of the connection which
exists between these lesions, declares that a sharp division
between adenoma and hyperplasia in the liver cannot be
made. lie claims to have seen, as Van Heukelon did before
him, the transition forms between hypertrophied liver cells
and tumor cells. The relationship between hyperplastic
processes and tumor is more important when it has to do
with cells that possess great jDOwers to proliferate and regen-
erate, c. (J., surface epithelium and the epithelium of super-
ficial glands. In discussing this subject Birch-llirschfeld '
makes the statement that such atypical hyperplastic growths
show in the excess of their regeneration certain points of
similarity to tumors, and it may be accepted that they may
become changed into tumors; he also states" that the pos-
sible occurrence of growths which represent transition stages
between hyperplasia and tumor can not be excluded.

The effect of a productive inflammation or inflamiuatory
hyper]ilasia upon mucous linings is either a dilfuse and uni-
form thickening nr the formation of the isolated jtolypoid out-
growths. As tlic gross appearances change from a diffuse
process to dispersed or widely scattered growths, the likeli-
hood of the inflamuuitory origin lessens, for the conception
of a tumor is connected with the local limitation of its early
growth (Thoma). But to this there are exceptions, for " the
inflammatory new growths, which are due to atypical pro-
liferation of epithelium, fend to form either single, tumor-
like jn-otuberant growths or multiple growths over a con-
siderable surface" (Birch-Hirshfeld).

The confusion which attends the wonl jiajiilloma is no
more attributable to its diversity of structure than to the
question of its proper position in regard to tumors and the
hyperplastic inflammations. Birch-Hirschfeld '° states thai
in mucous membranes a diffuse or circumscribed polypoid
thickening may result from chronic catarrhal inflammation;
also, that in the nose" combinations of papilloma and hy-
perplasia of the mucosa occur. Klebs '" uses the isolypi of
the stomach to illustrate the effect of hyperplastic inflam-
mation in the production of papilloma. In the statement
by Orth " concerning the papillomata of the Fallopian tube,
that it is difllcult to determine with certainty to what ex-
tent they are caused by inflammatory growths of the folds
of the mucosa, we have further evidence of the confusion.

6 Lelirbueli der spec. path. Anatomie, i, p. 9.')7, 1S97, Berl.
1 Arch. f. path. Anat. (etc.), cli.K, p. 290, 1900, Berl.

8 Grundriss der allg. Pathologie, p. 144, 1892, Leipzig.

9 Lehrbuch der path. Anat., i, p. 180, 1890, Leipzig.

10 L. c, p. 137.

" Lehrbuch der path. Anat., ii, p. 4.'i0, 1894, Lcijizig.

12 L. c, p. fil.5.

i^Lehrbnch der spec, jiath. Anat., ii, p. .539, 1889, Berl.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Such uncertainty of classification leads naturally to the
use of terms which are devised to bridge over the difficulty.
Such a title, alluding both to the process of hyperjilasia and
to the admixture with tumor, is used by Hauser" in his
report of a case of " Polyposis intestinalis adenomatosa."
In' this case there were disseminated polypi consisting largely
of atypical epithelial growths not only throughout the intes-
tinal canal but also in the stomach. Hauser refers to three
other similar cases. Petrow " has added another in which
there were numerous single or clustered, large and small
polypous growths in the stomach and the entire intestinal
canal, together with every evidence of a severe chronic in-
flammation in the mucous coats involved.

Quenu and Landel '" have recently collected 43 cases in
which the large intestine was the seat of a more or less ex-
tensive polypous hyperplasia. From the frequent history
of diarrhrea, these authors believe that the process has its
origin in inflammatory conditions, and this opinion is
reached after a thoughtful consideration of the possibility
that the intestinal disturbances might be secondary to the
multiple adenomata. In a previous article by the same
authors " there is even less doubt displayed respecting the
identity of pedunculated adenomata of the rectum with hy-
perplastic processes, for the statement is made that " they
are more or less directly dependent upon an inflammatory
reaction."

Sklifossowsky," after describing two benign papillai'v
tumors in the mucous lining of the stomach, states that they
originated from a hyperplasia of the mucous coat due to
long-standing irritation; he likens them to the knob-like
projections of the Stat mamelonne. His interest in these
growths was largely due to the fact that all transitions were
found in them between the diffuse thickening of gastritis
proliferans and the tumors described.

Further evidence is not necessary to illustrate the fact
that hyperplastic processes in the mucous lining of the
gastro-intestinal tract, like those of the liver, are closely
allied to the processes of tumor-development; or that there
are certain interposed lesions which might be accepted as
proof of the continuity of processes having as their onset
chronic inflammation, and, as their termination, tumor-
growth. The analogy will be more complete with the dem-
onstration of cases such as are hinted at by Birch-Hirsch-
feld '° in the following proposition : " It is probable, but
not proven, that certain forms of primary carcinoma of the
liver may have their origin in a further atypical development
of such liver adenomata." The fact that the hyperplasia of
the gastro-intestinal mucosa has, as its end product, the

!■' Deutsebes Arch. f. klin. Med., Iv, p. 429, 189.5, Leipzig.

'» Bolnitsch. gas. Botklna, 1896, St. Petersburg. From the summary
of Russian literature by Maximow and Korowin, Ergebnisse d. allg.
Path. u. path. Anat., Lubarsch and Ostertag, v, p. 73.5, 1898, Wiesbaden.

i^Les polyadenomes du gros intestine. Rev. de Chir., xi.v, p. 405,
1899, Paris.

1' Rev. de gynec. et de chir. abd., ii, p. 484, 1898, Paris.

iSArch. f. path. Anat. (etc.), cliii, p. ISO, 1898, Berl.

"L. c, p. 743.

evolution of malignant neoplasms, leaves no room for con-
troversy such as has been noted with regard to multiple
adenomata and nodular hyperplasia of the liver.

In 42 cases gathered by Quenu and Landel of polypous
hyperplasia of the colon, there were 20 in which a carcinoma
of the colon was also present. In the series .of Hauser,"" of
carcinoma of the colon, five were associated witli more or
less extensive " polyposis,"' and in the stomach the same
author reports one case in which the process was combined.
(Case 25, p. 208.)

One of the cases of bcnig-n tumor of the gastric mucosa
which Sklifossowsky so positively ranks with the inflamma-
tory hyperplasias, possessed at the same time a carcinomn,
which was sufficiently interesting, on account of the early
changes it showed, for Israel to report it under the title
" Ueber die ersten Aufange des Magenkrebs." " Also, in the
case of Petrow, of diffuse gastro-intestinal polypous hyper-
plasia, death took place from invagination aud spontaneous
rupture at two places, where the growth had a similarity to
adenocarcinoma.

To substantiate the view that the polypous growth occurs
first and that the production of tumor follows, the following
citations will suflHce:

Orth,"" in considering similar growths in the Fallopian
tube, writes as follows: " Among the recently reported cases
of papillary new growths are some which may be correctly
deemed benign and others which are malignant; from the
great similarity of these to one another it is safe to accept the
view that there is at least a danger of cancerous transforma-
tion. Hauser, in the report mentioned of a case of
Polyposis intestinalis adenomatosa, claims (p. 44G) that one
must admit that the multiple warty growths have developed
first and that these later underwent a carcinomatous change.
CuUen,"^ after referring to the opinion of Lubarsch, that a
benign tumor is never changed into a malignant one, says:

" Case 4.262, which I have recently had the opportunity of
studying, shows beyond a doubt that such a possibility
exists." The case in question was that of a polypous ad-
enoma of the uterine mucosa.

The investigations on inflammatory hyperplasia with
tumor-formation in certain regions have been repeated by
Stoerk " in the urinary tract. He describes a case of papil-
lomatosis of the urinary bladder, ureter and pelvis, of the
right kidney, and was able to find only two similar cases in
the literature. He considers the process as an unusual
form of chronic inflammatory hyperplasia, and compares it
with Gastritis proliferans. More commonly the chronic in-
flammation in the urinary passages terminates in a hyper-
plasia associated with the formation of cysts. That certain
cases should display both features of the process is not sur-

■» Das CylindiTepithel-carciuom des Magens und des Diclvdarms, p.
261, 1890, Jena.

"Berl. klin. Wchn?chr,, xxvii, p. 649, 1890.

"L. c, p. 539.

2' Cancer of the Uterus, etc., p. 3.55, 1900, N. T.

"Beit. z. path. Anat. u. z. allg. Path., xxvi, p. 367, 1899, .Jena.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 130.

prising. Litten "■"' has described " Ureteritis chronica cystica
polyposa." Cahen "" has one case, and to this Stoerlv adds
three more, in which the liyperphisia of the mucous lining
of the bladder was accompanied by carcinoma. Kehn "'
makes the interesting statement that in the majority of
tumors of the bladder a substance in solution in the urine
causes the tumor-growth by its chemical irritation; he has
observed three cases in which tumors of the bladder oc-
curred in men employed in the manufacture of aniline dyes.
Stoerk is inclined to lay strong emphasis upon gonorrhoea
as an etiological factor, and Kaufmann ^ has described the
occurrence of multiple polypi in the ureter from the passage
throiigh it of fitces from a fistulous connection between the
pelvis of tlie kidney and the duodenum. As an example of
the question which so constantly recurs — tumor or inflamma-
tion— and serving as an illustration of the apparent neces-
sity to separate these conditions, the following quotation
will answer:^ "The condition described might be classed
both as chronic cystitis and as tumor. ... I am inclined to
look upon the process as a chronic cystitis." This is in con-
cluding an article on Cystitis Papillomatosa, where the cysto-
scopic examination left the observer in doubt. In the recent
work by Mullen on Cancer of the Uterus, there is abundant
evidence that a diffuse polypous hyperplasia of the uterine
mucosa occurs and that this condition may be combined with
carcinoma. The illustrations on pages 514 and 516 show
its gross anatomy; some participation of the epithelium in
the process is evident, since in many ]daces it was many
layers in depth in both cases, notwithstanding that no
karyokinetic figures were found. Case 3,453 (p. 333) of
" adenocarcinoma of the anterior cervical lip ; commencing
adenocarcinoma of the posterior lip, apparently independent
of the former; papillary outgrowths of the uterine mucosa,
with suspicion of commencing adenocarcinoma of the body
of the uterus," is a striking analogy with the polypous hy-
perplasia with carcinomatous transformation observed in the
intestinal mucosa and the urinary tract. Perhaps the best
example of polypous hyperplasia described by Cullen is
Case G,G59 (p. 401). Occurring in a young woman, aged 30,
this author describes " a very unusual polypoid condition,"
in which " the mucosa, as a whole, presents a most unusual
picture, consisting of large polyp-like masses springing from
all parts and completely filling the enlarged cavity." His-
tolngioally, "one of the chief features is the preservation of
the himiua of the glands; few, if any, nuclear figures are
to be made out," and "the uterine muscle has not been
penetrated by the growtli ; in fact, at some points there still
remains a small amount of normal mucosa separating the
growth from tlie muscle." There had been no reciirrence
of tumor 11 months after the removal of the uterus. The
diagnosis was adenocarcinoma. There is but little doubt,

« Arch. f. path. Anat. (etc.), Ixvi, p. 13!», ISTfi, Berl.

ssArch. f. path. Anat. (etc.), cxiii p. 468, tSSS, "Berl,

" Verhandl. d. deutsch. Gesellsrh, f. Chir., xxit, s. 340, ISfl.i, Berl.

«» Cited by Stoerk.

29 F. Bierhoff, The Medical News, Ixxvi, p. 810, 1!)00, I'hil.

SO far as one can judge from the report, that in this case the
process was one of diffuse polypous hyperplasia which, so far
as the examination shows, had not at the time of removal
undergone carcinomatous change. That such a change
would have occurred, had it been undisturbed, might be in-
ferred from the continuity of process which has been shown
so far to exist between the polypous hyperplasia and car-
cinoma.

But it is especially concerning tumors of the Fallopian
tube that confusion has arisen; there has been quite a gen-
eral failure to recognize that a diffuse hyperplastic inflamma-
tion is possible— a process which is strictly analogous to the
polypous hyperplasia of other mucous surfaces — and that
in certain typical examples it is as distinct from tumor-
growth as gastritis proliferans is from carcinoma of the
stomach. Part of the confusion is no doubt due to the fact
that hyperplasia is so frequently combined with sacto-sal-
pinx. Slavyanski " has recognized this fact, as is estab-
lished by the frequency with which he uses the term sacto-
salpinr papiUomatofta, although he does not clearly distin-
guish between papilloma as a tumor and polypous hyper-
plasia due to chronic inflammation. He states that " with
occlusion of the abdominal end, the tube appears larger,
aside from the papilloma; products of the secretion both
from the covering of the tumor and the diseased mucosa
accumulate in the tube: thus saeto-salpinx becomes sacto-
salpinx papillomatosa (p. 113)." Numerous investigations
in lower animals have proven that when the outer end of
the tube is closed a retention cyst is the result," Un-
doubtedly in many cases the inflammatory process which
leads to the hyperplasia of the mucous lining of the tube
causes the closure of the abdominal end. As a typical ex-
ample, the case reported by Doleris and Macrcz "' will an-
swer. He removed from a woman, aged 37, a growth of the
right tube which was adherent to the liver and measured 30
by 30 cm. It consisted of a sac filled with grumous, viscid,
yellowish fluid; its walls were 5 to 10 mm. and the lining was
beset with pin-head to pea-sized papillary growths, which, on
microscopic examination, consisted of villi with rarely more
than one layer of epithelial cells as a covering. This is the
second growth of this sort removed by Doleris; the other,
in 1891," being the first observed in France. The woman
was 28 years old; the growth was in the right tube and the
inner one-fourth of the sacto-salpinx contained no jiapillary
growths. Clark lias reported a similar case " of a cystic
growth of the Fallo|iinn tube 13 liy 13 cm., or ono-hnlf tlie
size of a man's bead, in which the inner surface was studded
with thick papillary growths except at one point, where the

'"Special Pathology and Therapy of the Diseases of Women, vol. ii,
Diseases of the Fallopian Tubes and Ovaries (Russian), 1807, St. Peters-
burg-.

" C. Gebhard : Patholoiiisclie Anatoniie der weiblichen Sexualorii'ane,
pp. 436-7, 18(19, Leipzig; also: Ergebnisse d. allg. Path. u. ]iat'i. Anat.,
1898, V, 741 (work of Sadkowsky), W'iesbaden.

Si La Gynecologie, iii, p. 389, 1898, Paris.

''Nouv. Archiv. d'Obstet. et de Gynec, vi, p. 11, 1891, Paris.

s-" Johns Hopkins Hospital Bulletin, ix, p. 163, 1898.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

surface for au area the size of a palm was smooth. The wall
of this cyst was thin; the warty growths were largely made
ujj of connective tissue, and the epithelial covering of these
was uniformly single-layered.' Although Clark ascribes the
process to inflammation, it is reported as the seventh in-
stance of papilloma of the Fallopian tuhe. Another in-
stance first reported on account of the concurrent appendi-
citis ^'' was shown on later examination of the sac," which
was as large as a foetal head, to contain the inner part of
the tube as"a curved cord on its outer surface. The lining
of the sac was beset with small growths covered with epithe-
lium; the crypts between the growths extended outward so
as to give to the section an appearance not unlike an
adenoma. The condition described in this case might be
considered as analogous to cystitis cystica of Stoerk and
others, which led Aschoff to search for glands in the urinary
tracts of newly born infants. It is essentially the same pro-
cess— a hyperplasia of the lining (sacto-salpinx villosa et
pseudo-foUicularis). Both this case and that of Montprofit
and Pillief" are included by Macrez in the table of benign
papillary timiors of the tube; in concluding the case above
mentioned, the following interesting statement is made:

" L'origine irritative de ces productions dans la trompe
ne doit pas surprendre, puisque Ton voit que dans les vis-
ceres comme le foie, le rein, la capsule surrenale, etc., les
formations adenomateuses coexistent avec la sclerose et
paraissent etre un des modes de reaction des cellules paren-
chymateuses aux irritations qui amenent Tepaississement
dii tissu conjonctive."

The second case of papilloma reported by Doran'" was
double-sided; the right tube contained over a pint of fluid,
the left a smaller amount. Both contained papillary growths
wliich Doran describes as warts " similar in principle to those
found in other structures, namely, overgrown papilla;, the
result of continued irritation."

It is certainlj' of doubtful propriety to consider these
growths, so clearly the products of an inflammatory action,
as " papilloma." Sacto-salpinx papillomatosa might be
altered with advantage to Sacto-salpinx polyposa, for the con-
dition is one of diifuse polypous hyperplasia associated with
the formation of a retention cyst and not one of tumor-
growth. By some observers the diffuse villous hyperplasia
associated with sacto-salpinx has been reported as carcinoma.
W. L. Jakobson '" has reported a case in which the papillary
growths almost filled the sac. Although the epithelium had
not proliferated so as to invade the musculature of the tube,
and notwithstanding that there were no metastatic growths,
the condition of the tube was diagnosed carcinoma by both
Jakobson and' Petroff, who made the histological examina-
tion. In the case reported by Hofbauer '° both tubes were

35 Bull. Soc. Anat. de Par., 1897, xi, n. s., p. ."ilS.

^V. Macrez : Des Tumenrs papillaires de la Trompe deFallope, p. 61,
1899, Paris.

3' Bull. Soe. Anat. de Par., 1893, vii, p. .50.5.

38 Tr. Path. Soc, 1888, xxxlx, p. 300, London.

39 J. akush. 1 jensk. boliez., xii, p. 29, 1898, St. Petersb.
"Arch. f. Gyniikol., Iv, p. ."JIB, 1898, Berl.

closed externally, but retention cysts were absent. The
lining of the right tube, in which the changes were more
advanced, possessed small miliary and larger growths, some
as large as two beans. From the gross changes and from the
careful description of the histologic structure, this might
also be considered as polypous salpingitis, did not the record
point so well to tuberculous salpingitis. The sac in the
case operated by Leopold and described by Fearne " measured
5 cm. in diameter and occupied the infundibulum and am-
pulla of the tube. It was filled with a soft vascular papillary
growth. Tlie lining folds have hypertrophied, branched,
and then, according to Fearne, undergone malignant transfor-
mation. The muscle fibers had disappeared by atrophy and
a firm connective-tissue wall had so successfully limited the
process that there were no metastatic growths and the pa-
tient was well li years later." The case reported by Sanger
and Earth," over which they hesitated long before conclud-
ing that it was one of carcinoma, which diagnosis has con-
stituted one of the principal factors of the present confusion,
was one in which the tubal mucosa was thickened so that it
resembled the cerebral convolutions in miniature. The
accompanying illustration, shov/ing the macroscopic appear-
ance of the lining, resembles greatly the mammillated appear-
ance of the stomach in gastritis proliferans. This thicken-
ing affected the outer one-half of the tube uniformly; there
were numerous nuclear figures in the epithelial cells which
covered the villi in a single layer, and largely from this his-
tologic similarity with " Adenoma malignum " of Euge and
Veit, these authors concluded finally that it also was carci-
noma. The diffuse character of the process in this case, and
the uniformity with which the tubal mucosa was involved,
point to a hyperplasia similar to that seen in other mucous
coats — to a condition resulting from inflammatory reaction
with excessive proliferation or the early disappearance of all
other changes but proliferation — a process which Adami, fol-
lowing Klebs, refers to as "neoplastic hyperplasia," and
which Hauser, as before noted, connects with tumors by the
term " polyposis adenomatosa."

It does not always happen that the outer end of the tube
becomes closed by the inflammatory process; the subsequent
invasion of the adjacent peritoneum, by papillary or warty
growths, however, is no proof that the process is one of
tumor-growth; for, in condyloma acuminata an exactly sim-
ilar process occurs — extension of a hyperplastic inflammation
by direct continuity of surface. The classical case of
Doran " is of this nature. The outer part of the right tube
was dilated and filled with cauliflower-like growths; these
were formed by villi covered by a single layer of epithelium
of which some colls were ciliated. There was also an enor-
mous ascites and pleural effusions which required frequent

•"tTber primiire Tubcncarcinom. Geburtshiilfe u. Gynakologie, ii,
p. .337, 1895, Leipzig.

«Tr. Obstet. Soc. (London), 1898, .xl, p. 303.

" Die Krankheiten der Eileiter, A. Martin, p. 353, 1895. Berl.

«Tr. Path. Soc. (London), 1880, xxxi, p. 174; Idem., 1883, xxxiii
Supplementary Reports, p. 49.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 120.

tapping; although it was impossible to remove the eutii-e
growth, uo recurrence had taken place IG years after the
operation.*' It is more reasonable to believe this case to be
one of hyperplastic salpingitis than of tumor. Doran, in his
original report, likened it to the venereal condylomas and to
the indammatory polypi of the tubal mucosa described by
Eokitansky and Hennig.

Another condition has been described by SchirschoS '" as
papilloma. It is that of a single pedunculated tumor which
arose from the lining of the tube 5 mm. inside the limbriaj;
the abdominal os was wide and gaping. The growth was
5 em. in length and made up of a cluster of smaller masses.
The exact pathologic position this growth should occupy as
regards the Fallopian tube will always be in doubt, smce
there is but slight mention of the large (wt. 410 g.) papillary
cystoma which was situated just below the outer end of the
tube. In other cases such localized growths have beeu cata-
logued as carcinoma. Stroganoif '' has described a single
pedunculated growth which arose from the mucosa by a
pedicle 1 em. in diameter. The tube containing it was
closed externally and held about 50 ccm. of the usual sero-
hemorrhagic fluid. The structure of this growth was such
that a diagnosis was made of " carcinoma cylindro cellulare.""
There is no mention of regional invasion, glandular involve-
ment or recurrence; the woman was 39 years old. Tuffier"
found in a tube, which was closed externally, pear-shaped
and as large as a fretal head, a dark, soft and friable mass
which was at first supposed to be free; in examining it a
narrow pedicle was found. The lining of the sac containing
this growth was, for the greater part, smooth and devoid of
epithelium. The examination of this growth alone, which,
like that of Strogonoff, was largely necrotic, led to a diag-
nosis of carcinoma (epithelioma).

Falk " also described a localized growth as carcinoma. On
the left side the tube formed a sac that contained a sauious,
semi-purulent fluid and in its outer part gelatinous cysts;
the sac formed by the right tube was as large as a child's
head. It contained a similar fluid, free, grayisli, villous
masses, and on the posterior wall springing from the mucosa,
a growth the size of a walnut; this contained gland-liko
structures, and from its histologic resemblance to the case
of Sanger and Barth, a diagnosis of carcinoma was reached.
It is obvious that iii this instance the chronic inflammation
on one side caused sacto-salpinx with hyperplasia of the li-
ning and the formation of pseudocysts; on the opposite side,
sacto-salpinx with the production of a localized growth. In
eases of this nature, the effort to separate tumor and hyper-
plasia meets, in the localized nature of the growth, an ob-
stacle which is at present insuperable. If there occur in

<5A System of Gynecology, by many writers, edited by T. C. Allbiitt
and W. S. Playfair: Diseases of tbe Fallopian Tube by Alban Dorau,
p. 806, 1897, London.

«Bolnitsch. gas. Botkina., Nos. 42-44, 1898.

■"Collection of works in Obstetrics and Gynecology, dedicated to
Prof. K. F. Slavyanski (Russian), p. 227, 1894, St. Petersburg.

48 Ann. de Gyn^c. et d'Obst., 1894, xlii, p. 203, Paris.

"Berl. kliii. Wcbuseli., 1898, xxxv, p. 5.54.

such localized growths evidences of the multiplication of
cells — nuclear figures — or if alterations are found in the
morphology and staining reactions of the cells which would
indicate that they have not reached an adult type, the pro-
cess is certainly more like tumor thau like hyperplasia. But
between hyperplasia and carcinoma there is a considerable
gap. Hauser, after describing the multiplication of the
glands in the polypi of the intestine, makes the statement "°
tliat it should not be understood that all such growths are of
necessity precursors of carcinoma. With the article of
Schmieden'' theie are portrayed atypical karyokinetic
figures in the liver cells which form the adenomata. In
short, it seems to nie that the case described by Falk does
not correspond to carcinoma so much as it does to a benign
and localized growth; here it is necessary to recur to a prop-
osition made earlier — that it is doubtful whether the nar-
row distance now separating hyperplasia from benign tumor
will be increased. It is reasonable to believe that there
should occur in the lining of the Fallopian tube regenerative
processes, similar to those of glandular organs and structures
possessing glands, the products of wliich are closely allied
to adenomata.

The foregoing considerations demonstrate the imper-
ceptible transition of hyperplastic processes of the tubal
mucosa — belonging properly to the salpingitides — into those
of true tumor growth; and that these may terminate in the
production of benign tumors. The literature of tubal
tumors also contains abundant evidence that the transition
of villous hyperplasia into growths that at least possess some
indications of malignancy is an equally gradual one. The
tumors demonstrated by Kaltenbach as double-sided tubal
carcinoma °" were later elaborately described as papillomata."
Carcinoma is positively excluded in the following words:
" Aber nirgends lasst sich doch ein Anhaltspunkt fiir eine
wirkliehe Carcinombildung finden, audi da nicht, wo die
Neubildung mehr einen parenchymatosen Character hat, und
von einer Zerstorung des bindegewehigen Papillarkorpers
durch eingedrungene Epithelmassen ist nichts zu sehen."
Notwithstanding this statement, there was a recurrence
within IS months.'* In Eckhardt's '' case the cyst formed by
the dilated outer portion of the tube had small elevations on
its external surface which, on microscopic examination, were
found to consist of solid outgrowths of epithelium. In a
report by Fabricius,'" the left tube was removed and the
growth that it contained pronounced papilloma by Paltauf.
The right adnexa appeared normal and were left in place.
Five months later a large growth occupied the right side of
the pelvis, and masses removed from where the left tube
had been amputated were declared by Paltauf to be carci-

5»L. c, p. 447.

51 L. 0.

5- Centralbl. f. Gynak., xvi, p. 357, 1889.

s'Ztsch. f. Geburtsh. u. Gyniik., 1889, xvi, p.

"Doran Tr. Obstet. Soc, 1898, xl, p. 200.

"•Arcliiv f. Gynak., 1897, liii, p. 183, Berl.

■«Wien. klin. Wcbnscb., 1899, xii, p. 1230.

564, Stuttg.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

noma. lu the instance chronicled by MichnofE," the folds
of the lining of the left tube were thickened by many strata
of epithelium and the muscular layers in some places were
invaded through their entire thickness. The condition in
the right tube considered by Michnoff as papilloma corre-
sponds very well with sacto-salpinx villosa; the epithelium,
rarely more than a single layer, covered papillary growths
1 cm. tall, and these filled the canal near the outer end of
the tube; the os abdoniinale was closed and a cyst had
formed there the size of a small hen's egg. In a case re-
ported by Krctz as papilloma," sacs had formed on both sides
tliat exhibited externally small, white, soft, flat nodules. By
the study of serial sections, these were found to be produced
by the growth outward of the crypts between villi; the diver-
ticula produced in this manner usually possessed a single
layer of tall epithelium; where the epithelium was in two or
three layers the cells were shorter and nuclei more spherical.
Such cystic formations were found within the lymph
channels.

Although it is not within the scope of this article to insist
on the glandular character of the epithelial tubal tumors,
certain facts may be pointed out. It is obvious that the five
cases above cited as examples of growths that were removed
during the transition between hyperplasia and tumor are
very similar to proliferating papillary cystoma of the ovary.
This similarity with ovarian tumors has been dwelt wpon
by many writers. Gebhard'" compares them with uterine
■ carcinoma in the following words : " Obwohl ich selbst, wie
eingangs erwiihnt, keine eigene Erfahrungen liber das Tuben-
carcinom besitze, so bin ich doch bei der Durchsicht der in
der Litteratur niedergelegteu Beschreibungen des mikro-
skopischen Verhaltens dieser Geschwuslt zur iiberzeugung
gekommen, dass dieselbe histologiseh durehaus mit dem
malignen Adenom u. Adenocarcinom des Uteruskorpers auf
eine Stufe zu stellen ist."

The classification of tubal careinomata into purely papil-
lary and papillo-alveolar by Siinger and Barth °° is but a make-
shift for adenocarcinoma; as Cullen says,"' concerning adeno-
carcinoma of the uterus, " I am strongly of the opinion that
where the papillary arrangement is most marked, the growth
has started in the surface epithelium; whereas it seems
probable that when the gland-like arrangement is more pro-
nounced, the process has started first in the glands. The
simpler plan would be to consider all these merely as varia-
tions in one disease." Slavyanski "" would limit the term
adenocarcinoma to the latter form of Sanger and Bartli.
He separates them into two forms — carcinoma papillo-
matosa villosum and carcinoma C3lindrocellulare sen adeno-
carcinoma.

From the description of the following ease it may be seen
that the view of Cullen relative to the two "methods of growth
in tlie adenocarcinoma of jlic uterus is equally applicable to

"Meditsina, iii, p. 181, 1891, St. Petersb.
"Wien. klin. Wohnsch., 1894, vii, p. 573.
"L. c, ]i. 4.5.5.

fiO j^

«'L. c, p. 300.
«5L. c, p. llfi.

tubal careinomata; that there is a disposition to grow
towards the lumen in the form of branching villi as well as
outward into tlie muscular coat as sacs, diverticula or al-
veoli, and that these methods of growth are part of the same
process.°°

I received, June 22, 1899, from Dr. Henry P. Newman of
Chicago, a tumor which was removed by him at the West
Side Hospital. I am deeply indebted to him for the op-
portunity to examine it. The following abstract of the
clinical history was also obtained from liim:

Mrs. F., age 47, admitted to the West Side Hospital June
20th; in her early married life she had two miscarriages at
the third and fourth months of pregnancy respectively. Sub-
sequently, she gave birth at term to a child, which is now
21 years of age; delivery was instrumental and severe. Since
then she has been unable to carry a child beyond tlie third
or fourth month of pregnancy. In spite of many miscar-
riages she has enjoyed a fair degree of health until two years
ago, when menstruation became painful. The pain was re-
ferred to the sides and lower abdomen; it began just before
the flow and continued during the entire period; there was
also experienced general weakness and exhaustion on sliglit
exertion. One year ago she first noticed a protrusion from
the vagina which she took to be the womb; this has gradu-
ally enlarged, becoming more prominent after standing,
straining, and coughing. It has never been painful, but
has proved annoying in walking or sitting from its large size.
There has also been an enlargement of the abdomen until
it is now as large as a pregnancy at full term. She com-
plains of a frontal headache; she has a fair digestion; there
is no constipation or urinary trouble, but there is a constant
leucorrhoea and the discharge is often streaked with blood.

Operation. — Incision in the median line of the abdomen
8 cm. long; over two gallons of ascitic fluid escaped; the left
tube was very much enlarged and thickened; the ovary was
not involved. The tube was excised close to the cornu of
the uterus. Tlie right adnexa appeared normal; wound
closed with catgut and silk in layers. The protruding cul-
de-sac of Douglas was then opened from below, emptied of
its contents— a large amount of ascitic fluid — and the vaginal
fornix, which was so redundant as to protrude at the vulva,
was removed and its edges closed with catgut sutures. The
uterus was curetted and packed with iodoform gauze. There
was nothing removed from the uterus which led to any
suspicion of its containing a neoplasm. The patient,
though fractious and unmanageable, made an uninterrupted
recover)', leaving the hospital at the end of the third week.

Maceoscopical Appearance.

The mass consists simply of the left Fallopian tube. Its
uterine end tapers abruptly and the abdominal end is the
seat of an e\ul)(>ranf, eaulillower-like growth of new tissue
which appears to have burst fdvlli fi-iiiii flio tul)e (Fig. 1).

«3Tlii3 case was briefly reported at the Cliieagi) Gynecoloijical Society,
December 15, 1899, I)y Dr. Newmnii and myself.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 120.

The tube forms a small U-shaped bend, the convexity of
which is upward. The middle of this convolution measures
1.5 em. in diameter. It then bends downward and becomes
greatly dilated. Its external surface is covered with a
smooth, glistening, unbroken serous membrane which con-
tains many circularly arranged blood-vessels. All signs of
fimbrias at the outer end have disappeared. At the external
end is an abrupt termination of the smooth serous covering
which is overrun with tissue grown out of the abdominal
ostium. This new tissue consists in part of small, smooth
nodules which vary from .6 and .8 to 1,5 and 2 cm. in diam-
eter and of shaggy, rough tissue between the rounded parts.
This outgrowth is spread over more of the under surface of
the tube than elsewhere; it is very friable. The ovary and
its ligament form a pedunculated appendage to the tumor
mass and is small as compared to the large tube (Fig. 2).
The length of the growth is 13.5 em. The ovary contains a
large corpus luteum; the external surface is smooth. Just
in front of the tubo-ovarian ligament is a small accessory
tube measuring 28 mm., springing directly from the serous
covering of the main tube; its stalk is 1 mm. in diameter;
its outer end is dilated (Fig. 1). The weight of the entire
mass is 250 grammes. The tumor was hardened entire, and
without cutting, in Mueller's fluid and formalin (4 per
cent), except a small, irregular mass detached from the ex-
ternal end; this was hardened in strong alcohol (95 per
cent). When the hardening was completed the tube was
sectioned through its long axis. The center was found occu-
pied by a soft material of a gray color; it filled the canal,
and extends between the projecting masses of tissue which
fringe the lining (Fig. 3). The muscular coats are thin, but
the mucosa by its proliferation has invaded the necrotic eon-
tent of the tube for a distance which averages 1 cm. in all
parts of the tube. The proliferating lining is dotted over
with grayish, necrotic debris. The greatest accumulation
of this material has occurred in the middle of the tube where
it measures 2 cm. in diameter; at this point the remaining
5 cm. of the diameter of the tube is occupied mainly by the
proliferating mucous membrane. The muscular and fibro-
serous coats measure from 1 to 3 nun. in thickness. At the
uterine end of the tube there is a large amount of necrotic
material in the lumen and but slight proliferation of the
lining; at the abdominal end this condition is reversed.

Microscopic Appeahance.

Sections were cut from points along the whole length of
the tube and stained by various methods. The structure is
essentially the same in all portions. Set upon the muscular
coats, which are thin, are many papillary or villous growths.
They are usually tenuous stalks of connective tissue covered
with epithelium (Fig. 1), which branches and rebranches to
form a tassellated lining (Fig. 4). The epithelium consists
of many strata, of which only the deeper layers have a
columnar type. The nuclei are oval and irregular and do
not stain very strongly. The absence of a nuclear mem-
brane and the arrangement of the chromatin in certain

nuclei betokens poorly preserved karyokinetic figures. This
assumption is made certain by finding, after some search,
certain masses of chromatin which are plate-shaped and,
in other cells, the double plates of metakinesis. Such
nuclei in process of division are quite numerous; they are
as abundant in the outer strata as in the inner. In sections
stained after the iron-hoematoxylin method, these nuclei in
various stages of division form black masses. In some of the
dividing nuclei, in spite of the unfavorable fixation, the
centrosomes and the pointed ends of the groups of achro-
matic threads may be seen. There are no more irregular-
ities in these dividing nuclei than might be accounted for
by the hardening process. The layers of cells often number
ten to twenty and in the outer parts of the tumor near the
abdominal end they are even more numerous. The many-
layered appearance of the epithelium is not due to the thick-
ness or obliquity of the section, for in very thin sections cut
in paraffin and not more than one cell in thickness, at least
four to six layers are present, and this is true for regions
where the outer layers have undergone considerable necrosis,
where, in fact, the tips of papillffi are buried in necrotic
debris. In no place are any single rows of epithelium upon
a basement membrane found, such as occurs in the normal
folds of the tubal mucosa. With low powers of the micro-
scope the epithelial character of these cells is not clearly
evident because of the large size of the nuclei as compared
with the scanty amount of protoplasm surroimding them.
Even with the immersion objective some appear to possess
very little protoplasm. The nuclei alone average about
seven mikrons in diameter when they are circular; the
nuclei of the columnar cells measure in their long diameter
ten to eleven mikrons. Exceptionally very large nuclei
may be found which measure 15 to 20 mikrons in diameter.
In practically every nucleus of the resting cells there may
be found snuiU oval bodies colored a pale green, with the
hsematoxylin and eosin staining; with the iron and luema-
toxylin and considerable differentiation, these bodies are
much darker. Very rarely two occur in the same nucleus;
they are undoubtedly nucleoli; the peculiarity consists in
their large size. Very often they equal in diameter one-
third or one-fourth of the diameter of the nucleus; exception-
ally they occupy one-third of the entire nucleus. The
columnar shape of the cells close to the stroma is mani-
fested more by the shape of the nucleus than by the cell
body; in this region the nuclei are more closely arranged
in palisade form.

On the edges of these villous growths where the epithelium
is in contact with the necrotic material, and in places where
tlie edges of papillre are in contact, the epithelial cells have
undergone degenerative changes. Here occur occasional
nuclei, usually smaller, in which the chromatin is collected
in a few granules which stain intensely with nuclear dyes,
and such granules commonly festoon the inner margin of
the nuclear membrane or form a few crescent-shaped masses
on its lining. Such nuclei may appear devoid of cell bodies.
More frequently the necrosis has resulted in shrunken and

THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH. 1901.

PLATE XV.

Fig. I. — Tubal carcinoma — anterior
surface — natural size.

a. — Accessory tube.

Fig. 3. — Tubal carcinoma — posterior
surface — natural size.
(( Ovary.

Fig. S — Tubal carcinoma sectioned
longitudinally (three-fourths of natural
size).

(I. — Uterine end.

b. — Muscular wall.

c. — Necrotic tissue.

<l. — Papillary growth of the liii-
iug toward tlie lumen of the tube.

THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1901.

PLATE XVI.

fe.

: f

"mm

.mm-

-.■.-.saJrl*??'

■w ■"

■li;.'"

•/

- J.

Fig. i. — Villi that liave beeu seetionetl longitudinally and transversely;
Irimi tlie more central part of the growth.
II. — Necrotic tissue.
h. — Connect ive- tissue stalk,
f. — Ejiithelial cells in many strata.

■ _■ •%;.^v.>-.;, ...... ;,•

Fiu. 11. — "Invertintc tyi>e " of [uoliferation. The epithelium
between the papillary growtlis has proliferated outward toward
the muscular wall.

(/. — Necrotic tissue.

h. — Stroma.

<•. —Epithelium.

il. — Masses of epitlndinni linin;; cavities that have not been
opened in this section.

- /

Fig. 5. — Intricate arranuemcnt of stroma and epitlielium in which il
is ditlicuU to interpret the appearances without the study of serial
sections.

n. — Necrotic tissue.

h. — Stroma.

Fig. 7. — Showini;' the outward urdwtli of intervillous ejiithe.
Hum and the llattcnini;- of the thereby produced diverticula against
the muscular wall of the tube.

!(.— Diverticulum lilled with necrotic tissue.

Ik — Beginning papillary ]troliferntion of eidthelinin into
the diverticulum (cystl.

c. — Muscular wall of tube — only a jiart of wiiii-h is shown.

Makch, liioj.j

JOHNS HOPKINS HOSPITAL BULLETIN.

irrognlar miplri which stain deejjly throughout. Some
luick'i also liave long, twisted and irroguhirly tortuoiTS ex-
tensions. I'pon tlie ultimate border occurs a zone eom-
jiosed ol' dust-like granules of chromatin. In the necrotic
tissue in wliich the free ends of the papiUiB are embedded,
tliere may l)e found occasionally cells distinguishable by their
shape and size which have, however, lost all power to react
to nuclear dyes; they assume the same tint with eosin as the
granular nuiterial in which Ihey lie. Leucocytes arc present
in the epithelial covering of the }iapilla\ but only as iso-
lated cells; they are never accumulated in foci. Although
often of the polymorphonuclear type, there arc also many
with small round nuclei. In the layers of epithelium they
are easily distinguished from the epithelial cells in process
of division, but in the outer bordering zones of necrosis
they lose their identity. The leucocytes are often present
in the walls of the vessels of the stroma.

The stronui or connective-tissue stalks upon which the
epithelium is arranged to form papillary growths is very
delicate (Fig. 4). It consists of but little more than a ves-
sel wall. On each side of the lumen of the'vessel are from
three to six layers of parallel long cells which resemble the
cells of involuntary muscle. Their nixclei are slender and
from 20 to 30 mikrons in length and possess rounded or
abruj)t, blunt ends. The margins of these cells are obscure
when in contact; but in advantageous places it is possible to
see that the c(dls, like the nuclei, are spindle-shaped. Where
papillae have been cut across, the ends of the divided nuclei
of these cells ajipear round and the nuclear membranes
are much darker than when in longitudinal planes. Elastic
fibers (Weigert's stain) are present neither in the walls of
the blood-vessels of the connective-tissue stalks nor in the
layers of cells which surround the vessels. The endothelial
lining of the vessels is well preserved and shows no changes.
'J'here is some fibrin in some of the vessels and a snuill quan-
tity in the necrotic tissue between the papilla\; in either
case it never consists of more than a delicate network, ex-
tremely irregular. In sections from all parts of the tube
examined it is possible to find villous outgrowths, the epith-
elium of which has become completely necrotic, but in which
the stroma has not entirely lost its staining properties. Such
papillse^ stained with Van Gieson's stain, show prolongations
of the stroma extending f(n- even long distances into the
necrotic material before their nuclei, too, suffer chroma-
tolysis. In some papilhu the epithelium is entirely necrotic
upon both sides for only a short segment of its extent, the
fuchsin-stained stroma bridging over the defect.

It is evident from the foregoing description that the
papillary growths in this tumor consist mainly of an epi-
thelial covering of many layers and that the proliferation of
these has been so marked that they have filled the tube en-
tirely, distended it to a marked degree and have undergone
a considerable necrosis. The necrotic tissue has filled the
enlarged channel. These growths have been referred to as
stalks, as villous growths; when cut directly across, their
outline is circular. Such circular bodies lying in the midst

of the necrotic tissue have a striking appearance, since in
certain sections they are found at considerable distances
from any other tissue. Their outer margin is bordered by
the dark circde of pycnotie nuclei and chromatin granules;
the larger part of the body consists of the mass of epithelium
with the radially disposed nuclei, and a small vessel contain-
ing numerous red blood-cells forms the center.

As might be expected, these villous growths have no regu-
larity in their arrangement. The study of many sections
cut in series shows that the entanglement is very intricate
(Fig. 5). Arising from the wall of the tube, their course
may be directly toward the lumen or oblique or even par-
allel to the wall. To complicate the arrangement, the vil-
lous growths frequently join one another as well as branch;
consequently, in certain sections there may be seen at short
distances from the muscular walls regions made up entirely
of masses of epithelium, each mass consisting of a papilla
cut obliquely or transversely, and containing in its center
the blood-vessel. The edges of these clusters of epithelium
may be in contact and the line of division difficult to find;
in other places a narrow row of necrotic cells separates the
epithelium of different papilhe; in yet other places the
necrotic material has accumulated between them so that they
appear well separated.

In deeper zones nep.rer the muscular walls still another
peculiar appearance is obtained. Here the condition is
reversed; the stroma l)ordcrs (he ei>ithelinni on the outside,
and the epithelium lines a cavity filled with necrotic tis-
sue (Fig. 6). The examination of serial sections shows that
such cyst-like collections of cells are due to the growth out-
ward, toward the muscular layers, of that part of the mucosa
which intervenes between the villous prolongations; these
outward growths, when cut across, appear like small cysts
filled with necrotic tissue. As a rule the lining of these
cavities at the inner margin is sharp and distinct. The
layers of the epithelium are the same in character and num-
ber as those which cover the papillse. ]t is essentially the
same epithelium; the proliferation toward the lumen has
resulted in villous growths; toward the muscular wall, in
cavities; and these, when sectioned, appear like cysts. The
necrotic material which fills them usually stains lightly and
with eosin, but some are nu't with which are quite filled
with chromatin granules; such cysts (so-called for conveni-
ence) have a darkly stained content. Naturall}', such cavi-
ties are not always sectioned directly across; they often ap-
pear long and parallel to the muscular wall, or they are short
and more oval. The muscular wall is bordered in this man-
ner with but little interruption. It is obvious that the intei'-
papillary proliferation outward toward the muscular wall
has met with an obstruction; the distention of the tube has
not been able to keep pace with the proliferation of the
epithelium. Sections occasionally show the following con-
dition: the inner border of the muscular wall of the tube is
covereil with the saiue epithelium in strata as has been de-
scribed upon the papilhr. This epithelium lines a cavity
the opposite wall of wliich is quite distant (the width of

JOHNS HOPKINS HOSPITAL BULLETIN.

[Xo. 120.

the field, Obj. 3, Ocular 3, Leitz) and from the opposite wall
small villous growths project toward the muscular wall; the
remainder of the cavity is filled with necrotic tissue (Fig. 7).
These cystic formations in some sections, with the tissue in
which they lie, form a zone of considerable width just in-
side the muscular coats.

The tissue between the cysts is made up of the .<ame ele-
ments as those described in the stroma of the villus, ex-
cept that between the cysts it is abundant, whereas in the
villi it is insignificant. It contains the long spindle cells,
in all respects identical with those found in the villi; also
many vessels in which are little more than loose-walled
sinuses. Scattered leucocytes are seen frequently both
with round and with irregular nuclei. The greater part of
the stroma is apparently formed by fibers; some of them
stain red with Van Gieson's stain; most do not. There are
no elastic fibers among them. Numerous slender capillaries,
which are so delicate that a single red corpuscle fills the
lumen completely, are conspicuous in some sections in the
stroma; with the iron-hajmatoxylin stain, by which the red
blood-cells are made almost black, such capillaries, filled
with blackened cells, form a distinct delicate network.

Very peculiar appearances are caused by the occurrence
in the stroma, in certain places, of collections of blood-
serum'" — oedematous regions. The coagulated senun usu-
ally has small holes in it, oval in shape, which resemble the
holes in the cells of a fatty liver; often leucocytes are found
in the holes. The margins of the serum are beset with semi-
circular spaces; both the oval holes and the marginal de-
fects are due to tlie shrinkage of the coagulated serum. In
such oedematous situations, and in the tissue of the border-
ing zones, are found large swollen cells in all stages of drop-
sical degeneration; the wall of the cell forms a bag for the
network produced by the vacuoles. Such vacuoles do not
have the clear outline of holes which at one time contained
fat. Often considerable fibrin occurs in the oedematous
spots, and in places oedema is combined with hicmorrhage.
Plasma or mast cells are- not present in the oedematous
districts or in the stroma elsewhere.

The question naturally presents itself: Are there any loose,
unconnected, wandering epithelial cells in the stroma? A
careful search for these was made in different ways. Many
cysts were examined to see if at their outer margins there
could be found any evidences of the proliferation of the
epithelium outward into the stroma. Also many serial
sections were examined to see if any of the collections of
epitheliiim which form cysts were entirely unconnected and
cut off; a third evidence of such a process was sought for,
viz., cells in the stroma with nuclei in mitosis. All of these
signs of invasion of the stroma by loose and wandering
epithelial cells were absent. The proliferation of the
epithelium has been c?i masse; by the proliferation of the
tubal lining as a membrane; also by the production of a
lining of many strata.

" The fluid of the blood is readily coagulated by burdening in solu-
tions which contain chromic acid or its salts.

The muscular wall of the tube averages 1 to 2 mm. in
width. The muscle fibers are few in number; sections
stained by the fiicrofuchsiii mixture reveal a large amount
of fibrous connective tissue which takes a brilliaut red color;
this preponderance of fibrous tissue is especially marked in
the inner half of tlie wall. The circular coat has undergone
the greatest atrojjhy; only occasional strands of it arc
present.

The outer half of the fibro-muscvilar wall is more loosely
arranged. There are many large, flattened blood-vessels in
this portion and around them small aggregations of fat. In
the inner one-half of the wall occur occasional clusters of
lymphoid cells that show the effects of pressure, being greatly
elongated and parallel with the fibers. Such lymphoid nodes
made up entirely of cells that correspond to small lympho-
cytes occur in all sections. In a few sections there arc
islands of cells that present a different appearance; closely
aggregated cells with pale nuclei form an elliptical clump
that possesses a very definite margin. Careful examination
fails to reveal any nuclear figures in these cells; their nuclei
possess very little chromatin; their arrangement is quite
irregular; for these reasons and the fact that no lining
cells can be found for the spaces in which they lie, a con-
clusion was reached that these islands have resulted from
the proliferation of the endothelial lining of lymph chan-
nels. Still other islands of cells leave no doubt but that the
proliferating ejiitheliiiii! has penetrated deeply within the
fibro-muscular wall. In a few. sections, lying nearer the
inner border of tliis wall, are irregular tubules lined with
epithelial cells. The nuclei of the cells are long, occupy
most of the cell and stain deeply. The cells are columnar
and in places two or three strata in depth. Some of these
tubules occur within lymph channels, for outside the deeper
and more columnar cells the endothelial lining of the chan-
nel is easily recognizable. Since these deeper prolongations
of the epithelium were found so seldom, no effort was made
to prove their connection by serial sections with the more
centrally located parts of the tumor. The ovary contained
no tumor tissue.

From Dr. W. W. Sheppard, the family physician, it was
learned that for some time after the operation the patient
was " nervous and hysterical," but improvement was steady
and she was soon able to be up and around the house a part
of each day. About nine or ten weeks after the operation
ascites reappeared and upon vaginal examination a tumor,
the size of an orange, was found on the left side. The
ascites was relieved by tapping two or three times, the first
being done on November 1st. During the month of De-
cember Dr. Byron Eobinson was called in consultation. He
has informed me that he found the abdomen enormously
distended by a large tumor and considerable ascitic fiuid.
The patient was sitting up and able to walk about the
house; her general appearance was cachectic, pulse 120, tem-
perature 100'^ F. Tlie tumor arose from tlic small pelvis
and upon vaginal exaniiiiation was found to be fixed, except
its uppermost portion, which was slightly movable. It was

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

located chiefly on the left side. The uterus was slightly
enlarged.

Operation (by Dr. Eobinson). — Upon opening the abdom-
inal cavity with a long median incision the entire peritoneum
was found studded with paiiillomatous growths which varied
in size from those barely visible to some as large as a hen's
egg. The larger ones were located in the lower, left quad-
rant of the cavity, and in this jjosition were adherent to one
another so as to form an irregular mass. There were ap-
proximately two gallons of a clear ascitic fluid, similar in tint
to pale ale, in the cavity. The irregular tumor on the left
side was firmly adherent to the left lateral wall of the small
pelvis; it extended ujiward so as to be in front of the sig-
moid; the omentum was firmly adherent to it, and in the
omentum near the tumor and also in the adjacent mesen-
tery were many small shot-sized and pea-sized warty growths.
Most of these growths had a pale yellowish color a,nd were
like a fresh brain in consistency; some of the smaller
growths appeared very vascular. All of the larger growths
were removed.

Eecovery followed the second operation without any
special events. At present she is able to perform some of
her customary household duties. The ascites returned
gradually so that about five months after the second opera-
tion paracentesis was necessary for the patient's comfort;
and it has been practiced every two or throe weeks since.
At one time eleven quarts were removed, at another twelve
quarts; the fluid maintains its former characteristics. A
sample of this fluid showed on examination the following
features: sp. gr. 1007, alkaline reaction, a large amount of
albumin, absence of sugar, a moderate amount of proteids
(biuret reaction), absence of bile, and .3 of 1 per cent of
urea. I received the tumor masses removed by Dr. Eobin-
son after they had been in a weak aqueous solution (1 per
cent) of formalin for several days.

Macroscopic. — They consist of three large masses and
about a dozen smaller; altogether they weigh 1,3.j0'
grammes. The largest piece measures 16 X 13.5 X 4 cm.
and is disk-shaped; on section it presents a granular surface
which resembles somewhat adipose tissue. Its external sur-
face is smooth except for tag-like, torn adhesions. Its con-
cave side has a furrowed and trabeculated appearance. The
next smaller in size is very irregular in form, measuring
12 X 10 X 5 cm.; it is very rough and nodular externally
and in spots has been torn. The smallest of the large pieces
measures 11 X 7.5 X-l.S cm., and on section is found to pos-
sess a much softened, necrotic center. One of its flat sur-
faces is quite smooth. All of the smaller masses are very
irregular; some appear to be little more than fibrous tissue,
others resemble the larger masses.

Microscopic (continued). — Sections were made of all the
large growths, and some of the smaller, and stained by vari-
ous methods. A large part of all the growths consists of
necrotic tissue ; many sections contain little else. The
necrosis is most marked in and around the central portions;
svich necrotic tissue stains lightly or darkly according to the

degree of chromatolysis; varying degrees of oedema and
quantities of fibrin occur as well as small hisemorrhages. In
sections where necrosis is less marked, the appearance of
the innermost parts of the tubal tumor are duplicated; here
occur cross-sections of papillaj lying in the necrotic tissue
which are in all respects similar to those in the tube in size,
shape, paucity of stroma and number of epithelial strata ;
the cpitlielial cells contain similar large nucleoli. Xaryo-
kinetic figures, however, are much more numerous; often
three, four or six dividing nuclei are present in a single
field of the immersion objective (celloidin sections, 15 to 20
mikrons thick). The stroma of the papillae —connective-
tissue stalks — has its origin in a capsule which surrounds
each metastatic growth more or less completely. Tlie cap-
sule is formed by long cells arranged parallel to the circum-
ference whose oblong nuclei contain nucleoli which are
barely visible; these cells are not arranged in layers, for the
nuclei have been cut in all possible diameters; the cells
resemble the " fibroblasts " of organizing granidation tissue.
In sections of the various metastatic growths, and even in
different sections of the same growth, the capsule shows
large blood-vessels, regions of necrosis and of ha?morrhage
and thrombosed vessels. In regions just internal to the
capsule, where the papillomatous growths have been so
luxuriant that the papillaa are in contact and a tissue has
been produced which appears solid and granular, if the
stroma be examined in such places the conneclive-tissue cells
arc also found with mitotic figures. They are never as
abundant as the dividing nuclei of the epithelium; that the
stroma or supporting tissue contains cells which are multi-
plying is be3'ond doubt; that these cells are the same as those
which constitute the stroma is also certain, since all stages
of multiplication by indirect division may be found and also
for the reason that there are no other cells in the stroma
with resting nuclei than those described. It may be inferred
that this difference between the stroma of the papillae in tlie
primary tumor and that in the papillaj of the metastatic
growths is due to more favorable conditions of nutrition; it
is also possible that the more rapid proliferation of the
epithelium, as is shown by the abundance of dividing nuclei,
has in itself led to a proliferation of the cells of the frame-
work, and that tin's has been sufficient in amount to allow
the observation of occasional dividing nuclei in the stroma
cells.

This condition of embryonal stroma and embryonal
epithelium, since both contain dividing nuclei, has resulted
in a line of demarcation where epithelium and connective
tissue meet, which is much less distinct than similar lines
of contact in the primary tumor. In regions close to the
capsule, where there has been a rich growth of papillse and
necrosis has not occurred, the indistinct line of contact and
the entanglement of pajiilln? renders it difficult to distinguish
between epithelium and connective tissue. Some aid may
be had fniin tlic coliiniiiar po-^ition of the nuclei of the
epithelium on the stronui, but this does not always obtain;
in other places the epithelium has contracted away from

JOHNS HOPKINS HOSPITAL BULLETIN.

[Xo. l-M.

the stroma so that a narrow siaace is present. The blood-
vessels in the stroma have very little wall; they resemble the
vessels comniojily eneountered in a small spindle-eelled
sarcoma.

Among tile tumors of the FnUopian tube that can be con-
sidered as careinomata, this case is uni(|ue in the following
particulars: The os abdominale was evidently open, since
there was not formed the usual sac, and invasion of the peri-
toneal surface and adjacent tissues probably took ])lace via
this opening by continuity of surface. The case is also
remarkable in that large secondary tumor masses were re-
moved from the abdominal cavity, the patient still living,
although slowly sui'cumliing to the disease."' The similarity

*' The patient died Feljniary IS, lilOt ; tlirousli tlu- Ivindness of Dr.
Sheppard, a uecropsy was secured, tlie details of wliicli will be shortly
published.

in method of growth and general histologic structure to pro-
liferating cystadeiiomata of the ovary is continued in the
comparative benignancy of the peritoneal metastases.

The appended table comprises 21 eases of carcinoma that
were selected from .j2 cases that have been reported as
[lapilloma or carcinoma. 15 of the 52 were excluded by
reasmi of insultieient data; of the remaining 37 some have
been ^hown to be instances of hyperplasia of the tubal mu-
cosa due to inllammation, a process usually combined with
sacto-salpinx, that leads to the formation of benign localized
growths whose position in the domain of tumors is very
questionaljle, or to more diffuse growths that may possess
some of the characteristics of malignancy; the latter resemble
the careinomata that develop in scars, burns or fistuhT' from

long-continued irritation.

AUTHOR, TITLE
AND PT.ACE OF
PUBLICATION.

E. SeniJrcr: llebcr eiii
primiiros Sarkom dur
Tuben. Centralbl.l.
Gvnak., ]88ti, X, p.
601, Leipzig.

E. G. DrUimann :
Ueber Cai-ciiioina
Tubie. Ztsch. f. (ic-
hurtsh. u. Gyniik.,
1 88, XV, p. 312,
Stuttg.

A. Doran: Primary
Cancer of the Fal-
lopian Tube. Tr.
Path. Soc. (Lonciojii,

1888, XXXIX, p. 2IH.

C. J. Eborth and H.
Kaltenbach : '/aiv
PathoIog:ie der 'ru-
bon. Ztsch. f. Gc-
burtsh. II. Gvniik.,

1889, XVI, p.' 3.17,
Stuttg.

T. Landan and ,1.
Kheinstein; Rei-
trilge znrpatholo-
prischrn Anatoniip
der 'rul)e. Archi\-f.
Gyniik., 1890-lU.
XXXIX,p.273, licrl.

S. D. Michnoff: A Case
of Primary Carci-
noma of the Fallo-
pian Tubes (ttus-
sian). Moditsina,
1891, III. p. ]81, St.
Petersb.

P. Zweifel : Vorle-
sungen iiber klin-
ischc Gynak., ]8»;;,
p. 13il, Herlin.

F. .T. E. Wp.sterniark
and U. Quesnel : Ett
fall af dubbelsiiiig
kancer i tubip Fal-
lopii. Nord. Med.
Ark., 1893. XXIV,
Nr. 2, p. 1. .Stock-
holm.

UILATERAI. OK
UNILATERAL.

liilatcral.

Kight tube.

Hilateral.

Kight tube.

left tube.

Biliteral.

Jiilateral.

CONDITION

OF THE

OPPOSITE TUBE.

Pyosalpin.x.

Left tube at oper-
ation appeared
small.

Outer end closed
and a sac f*u*mcd
that containeii
.500 ccm. of
bloody, thin
fluid.

Sacto-sali)inx
paplUomatosa.

CLOSURE OF OS

ABDOMINALE

AND FORMATION

OF A SAC.

In both tubes
there occurred
two dilatations
or sacs.

The outer I'Hil,
greatiN ■liiatpd
opi'iiiil inio an
al)sci'ss ca\ ity.

Outer end closed ;
a sac formed.

L.— dilated to size

of thumb.
It.— large I-

(faustgn'issc.l

Sac fornicfl on
right side.

Left tube formed
a sac as large as
a large list.

Large sacs on
both silk's. L.
tube 20 (in. lone
and 8 cm, I hick.

Sacs formed on
both sides-
larger on left.

KECUHHKNCE

OR RECOVERY.

DEATH SOON

AFTER OPERATION.

Tumor found at
necroi)sy.

I>eath on sixth
day after oper;
tiou.

Recurrence: li\'ed
nearly eleven
months after
ope ration.

Recurred in 18
months.

Recurred in 10
months.

Iteeui'rence in 7
months.

PresumaVily re-
currence, since
patient died l>i
years after
operation.

Recurrence:
death in ti\'e
months.

CONCERNING
METASTASIS, IN-
VASION OF
ABSCESS CAVITIES,
ETC.

In Douglas's
pouch a small
growth.

The tuuKtr had
in\aded two
alisccssca\'ities.

A small nodule in
the "exca\atio
vesico-uterina.''

A swollen l.\iuph
gland in the
small pelvis.

Lumbar glands
inxaded.

.^ubjieritonca!
nodules noted
on the right
tube.

.\scites after the
operation, with
hard masses in
the^abdoraen.

A cyst occurred
at .iunction of
right tube and
o\'ary, size of a
hen's egg: it
was tilled with
clear tiuid.

In\asi(m of cyst

<if right ovary.
No exudate in

peritoneal

cavity at

necropsy.
Lymph glands of

small pelvis in-

\aded.
T.— no.lulcsfiiund

in the li\ er at

the necropsy.

CONDITION

OF THE

OVARIFS.

Uoth normal.

vVbscesscs in botl
o\'aries.

U.— cancerous.

Normal.

L.— ovary left in
Ijody, it was im-
l)cddeil in ad-
hesions.

R.— normal.

Normal.

L.— ovary cystic.
Jlonolocular
cyst size of an
orange.

REMARKS.

Reported as sar-
coma.

.\t necropsy,
tumor found in
the uterine
vesical and \a-
ginal mucosa.

Demonstrated
tirst as carcd-
noma.

lfepi>rtcd later as
paidlloma.

Carcinoma of the
cervix found at
the necropsy.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

AUTHOR, TITLE
AND PLACE OF

BILATERAL OR

CONDITION
OF THE

CLOSURE OF OS
AUDOMINALE

RECURRENCE
OB RECOVERY.

CONCERNING
METASTASIS, IN-
VASION OF

CONDITION
OF THE

RK.MARKS.

PUBLICATION.

l-NILATERAL.

OPPOSITE TUBE.

AND FORMATION
OF A SAC.

DE.\TH SOON
AFTER OPERATION.

ABSCESS CAVITIES,
ETC.

OVARIES.

H. Kretz : Zur Casu-

nilateral.

L,— tube 17 cm.

Small subperito-

Unknown.

Reported as

istic der Papillome

long and 6 to 8

neal nodules

papitloinata.

lier Eileiter. Wien.

cm. in diameter.

noted, exter-

K i-etz considers

klin. Wfhnsch., 1S94,

R.— tube similar.

nally on both

the case similar

VII, p. .57L'.

Both closed e.v-
terually.

tubes.
Invasion of the
l.vraph channels,
(histohigic
examination).

to that of Eberth
and Kaltenbach.

W. Fisehel : Ueber

Bilateral (?)

Condition of left

R.-tuhe formed

Recurrence :

Small nodules on

L'nknown.

Part of the cyst

eiiif'Ti Fall von pri-

tube not posi-

a sac 8by 4..5cni.

death se\en

external surfai-e

of the right tube

iniirem papilliiri'iii

ti\ely known.

months after

of riKht tube.

possessed a

Krel:)S der Muttur-

It was imbedded

the operation.

Abdominal ca\lty

smooth wall

ti-ompeten. Lapa-

in adhesions and

contained clear

ccjvered by a

rotomie, Heilung,

not removed.

ascitic fluid.

single layer of

Ztseh. f. Heilk., ksas,

short epithe-

XVI, p. H3.

hum.

A. Uosthoin : Pii-

Right tube.

At necropsy left

Sac ftu'med by

Recurrence :

Inguinal glands

Cyst of right

Necropsy by

m*ires medullai-es

tube found to

right tube sup-

death si.x

removed at a

ovary.

Chiari.

Cat-einoma tiilur.

contain meta-

posed to be

months after

second oper-

Ztsfh. f. Heilk,, 1S!W,

static iVt tumor

pyosalpin.x.

first operation.

ation. Retro-

XVII, p. ITT.

nodules.

Iieritoneal
glands found
iinaded at the
necropsy.

T. ,T. Watkiiis(aii«l E.

nilateral.

Both tubes large

Recurrence :

Ext. end of the

L.— ovary many

Ci)ndition of right

Hi^s' : Exhibitiuii ol

and formed bj'

death seven

right tube con-

corpora candi-

o\'ar.\' not clear.

unique iiiieroseopie

fourconv(du-

months later.

nected to a mass

cantia.

sections of papilloma

tions; both

4x4x5cm. This

and carcinoma of

closed e.\ tern-

contains a cen-

the tubes, etc. Am.

ally.

tral cavity beset

CJyn. and Obst. J.,

with sc\'eral

liitfT, XI, p. 273, N. Y.

wart\' growths.
Metastatic
carcinomata
on the ovaries
and on post,
surface of right
tube. Collec-
tions of luiniir

cells found in

h'mi»h channels

of wall of left

tube.

E. Falk: Fortschritte

Left tube.

I'nknown.

Left tube closed

Recurrence :

L.— ovary normal.

Tumor found in

u. jfe^enwiirtifi-rr

externally. Sac

death seven

the uterus in

Stand der \ ayinalcn

formed.

months after

mucosa n4-ar

Operations terlinik.

operation.

right ostium

Tlierap. Monatsh.,

and diagnosed

18i»7, XI, p. ai:j, Uerl.

as sarcoma \vas
siipp(iscd to be
respotisilile for
recurrence and
death.

K. Eckardt: Eln Fall

Left tube.

Normal. (Doran*.

Sac formed by

Healthy a few

Subperitoneal

Both normal.

Broad ligament

von primiirem Tnb-

the left tube

months later.

elevations, size

shortened by

encarcinom. Arcli.

size of child's

Subsequent

of hazel-nut.

invasion of the

t. Cvnak., 1897, LI II,

head.

history un-

make external

tumor.

p. 18:1.

known.

surface irregu-
lar.

A. H. PiUiet: Epithe-

Hi-ht tube.

CrdiUown.

Ca\ity in the

History not

Invasion of the

Condition of left

lioma de la tronipe

right tube oi)po-

known.

lymjih channels.

ovary unknown.

uterine. Bull. .Soc.

site o\ary.

(histologic ex-

R.—in\aded by

Anat. de Par., 18117,

amination.)

tumor in its

XI, p. 956.

(juter part only.

C. H. Roberts : A Case

lUsjht tube.

•■ The loft tube

Outer end of

Well ten months

Normal.

\'ery brief histo-

of Primary Carci-

inflamed and

right tutie

later.

logic descriiJ-
tion.

noma of the Falloi>-

closed."

closed : sac

ian tube. Tr. Obst.

formed.

Soc. London, 1898,

XL, p 189.

J. Fabricius: lieitriiK-e

Left tube.

At first operation

Supposed to be a

Recurrence 11 \e

Llnknown.

At the first oper-

zur Casiiistik der

the right adne.xa

p.vosalpinx until

months later

ation masses
removed were

Tubemarrinoiiu'-

appeared n<)r-

it was cut.

when a large

Wien. kliii.Wiliiisrli.

inal : at second.

mass tilled the

in-onounced

1899. XII, IJ. \-£U.

thickened.

right half of
the pelvis.

papilloma.
At thi- second
(qicration when
radical rcini>val
was found to be
inipossiljle,
masses were
removed that
were pro-
nounced
carcinoma.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 120.

AUTHOR. TITLE
AND PLACE OF
PUBLICATION.

BILATEB.iL OH
UNILATERAL.

CONDITION

OF THE

OPPOSITE TUBE.

CLOSURE OF OS

ABDOMINALE

AND FORM.^TION

OF A SAO.

REOtlRRENOE

OR RECOVERY.

DEATH SOON

AFTER OPERATION.

CONCERNING
METASTASIS, IN-
VASION OF
ABSCESS CAVITIES,
ETC.

CONDITION
OF THE
OVARIES.

REMARKS.

J. Fabricius: Idem.

Right tube.

L.—adoexa ap-

Abdominal open-

Recurrence: five

Carcinomatous

Right ovary en-

After second

peared normal

ins leads into a

months after

invasion of the

larged but

oi>eratinii a

at the opera-

cyst.

first operation

cyst on right

otherwise

lartre cyst de-

tion.

left adnexa and
uterus were
removed.

side. At the
second opera-
tion it was
found that the
entire peri-
toneum was
beset with
small tumor
nodules. The
metastatic
nodules on the
outer surface of
the uterus were
examined and
pronounced
adenocar-
cinoma.

normal.

veloped that
reached upward
to the na\'el and
finally evacu-
ated through
the rectum.

Danel : Essai sur les

Left tube.

Appeared healthy

Left tube formed

Recurrence took

Many peritoneal

Tumcurs malif^iios

at operation.

a sac.

place on the

gro^vths on the

primiti\('S (U- la
Tronipe rterine,

Not removed.

right side.

uterine end of
the tube.

1S9«, i*aris.

Enlarged glands
in the adhesions
around left
tube.

Tumor cells
found in the
lymph cliannels.
(Histologic ex-
amination.)

B. Friedenhelm:
Beitrag zur Lehre
\-om Tubencarcinom.
Ueber ein primiires,
rein alveoliires
Carcinom der
Tubenwand. Berl.

Left tube.

Unknown.

No sac formed.

History subse-

Left tube and

L.— smooth ex-

Tumor said to

quent to oper-

tumor adherent

ternally, size of

have had its

ation unknown.

to colon.

a walnut, con-

origin in an

Left parametrium
inHltrated with
tumor masses.

tained small
cysts.

accessory tube.

klin. Wchnsch., 1899.

XXXVl, p. 542.

E. Mercclis: Primaiy
carcinoma ot the
Falloitian tube. N.
Y. Med. J., 19UU,
LXXII. p. 45.

Right tube.

Left tube re-

Right tube 4 cm.

Recurrence on

Outer end of

L.— ovaiT small

moved. Con-

in greate.>it

right side 18

right o\ary in-

and firm— not

dition not

diameter.

months later.

vaded by tumor.

rt'moved.

described.

Outer end
closed.

R., the seat of
chronic inter-

stitial changes.

REPORT UPON A CASE OF GONORRH(EAL ENDOCARDITIS IN A PATIENT DYING IN THE
PUERPERIUM; WITH REFERENCE TO TWO RECENT SUSPECTED CASES.

By Norman MacLeod Harris, M. B.,
Associate in Bacteriology, Johns Hopkins University.

AND

William M. Dabney, M. D.,
Late Bcsiihnt Ohstelrician, Johns Hopkins Hospital.

Case 1. — I. T., aged 19, unmarried, was admitted to tlie
Obstetrical Department of the Johns Hopkins Hospital on
February 13, 1900, complaining of fever and wealvuess which
she thought were of puerperal origin.

Family History. — Negative as far as could be ascertained.

Personal History. — There is no history of the ordinary
diseases of childhood, nor of any acute infectious disease.
She has never had rheumatism, and states that previous to
the onset of the present illness she has always been a healthy
woman.

Marital and Menstrual History. — Tlie patient is unmar-
ried, and has had no previous children or miscarriages. The
menstrual history is normal in all respects.

Present Ulness. — The patient states that she was confined

on January 19, 1900, after a hard but non-instrumental
labor at term. (Child living.) During the course of the labor
frequent vaginal examinations without aseptic or antiseptic
precautions were made by those in attendance, and the third
stage of labor was furthermore complicated by a retained
placenta, which, after several attempts was removed manu-
ally, likewise without precautions. On the fourth day of the
puerperium she was seized with a chill, followed by fever,
and, later, sweating, and these symptoms have recurred
regularly every day since then. Other symptoms have been
headache and general pain in the limbs, nausea and vomit-
ing, tlie latter at times marked, and almost complete loss of
appetite. For the past few days .'jhe has had, in addition, a
rather constant cough, accompanied by some pain in the

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

side. The patient says she has been confined to bed prac-
tically ever since labor, and, though she has felt at times
better than at first, she has grown progressively weaker.

Physical Examination. — The patient's mental condition is
very dull apparently, answering questions poorly, and only
when repeated and asked in a loud voice. Well-formed and
well-nourished woman, marked ana?mia present, the lips and
mucous membranes being almost bloodless. Temperature
on admission 102.4° F., pulse 120.

Thorax. — Well formed. Respirations rather hurried, with
an occasional short, sharp cough.

Lungs. — Expans-ion fair, equal on the two sides. Vocal
fremitus normal. Percussion note normal throughout. On
auscultation at the base of each lung, a few very fine
crackles are heard on deep inspiration, and here and there
over both lungs an occasional medium moist rale. The
breath-sounds are normal.

Heart. — The point of maximum impulse is neither visible
nor palpable. No thrill or shock on palpation. Appar-
ently no increase in the area of cardiac dvilness. On auscul-
tation at the apex both sounds are practically obliterated
by a to and fro murmur, the systolic being the louder and
more intense. Both murmurs are transmitted and well
heard in the axilla. Preceding the systolic murmur a rather
loud rumble is heard at the apex, which is likewise trans-
mitted to the axilla. Over the body of the heart both mur-
murs are well heard. Over the base the systolic murmur
becomes diminished in intensit}', tlic diastolic more clear-cut
and marked. The presystolic rumble is lost. The pulse
is markedly collapsing in character, and there is a distinct
capillary pulse present.

Abdomen. — Looks normal. No rose-spots are visible.
There is no distension and the abdomen is everywhere soft
on palpation.

Spleen. — Not palpable.

Liver. — No apparent increase in dulnoss. The edge is
just palpable at the costal margin.

On palpation no mass can be felt in tiie pelvis on either
side or in either iliac fossa.

Legs. — Q<]dematous and slightly swollen. No swelling or
other changes in the joints noted.

Following admission on the morning of February 13th, the
patient had several vomiting spells, attended by signs and
symptoms of collapse, her skin becoming cold and clammy,
and her pulse dropping from 120 to 80-90 to the minute, with
an occasional intermission. When first seen in the afternoon,
several hours after admission, the patient looked septic,
but seemed to be in fair general condition. Temperature
at this time was 101.6° F., pulse 113 to the minute, rather
weak and of poor volume and tension. When seen again
about 7.30 P. M., she was found to be in far better general
condition, though markedly drowsy. Her history was taken
at this time, and the physical examination made. A pro-
visional diagnosis of ulcerative endocarditis of the aortic
valve, secondary to puerperal infection, of probably strep-

tococcic origin, was made at this time. During the night
the temperature again rose, reaching its maximum, 103° F.,
about midnight, pulse 120 to the minute and much weaker.
The general condition became very much worse, there being
marked prostration with drenching sweats as a particularly
noticeable feature. About 8.30 A. M., February 13th, the
temperature had fallen to 100.8° F., the pulse, 80 to 90 to
the minute, and of poor volume and tension. Attacks of
vomiting, attended by increasing signs of collapse, contin-
ued, and the general condition seemed very much worse than
at a corresponding time last night. Material for taking a
culture from the uterus was secured about 9 A. M., a fair
amount of bloody lochia being obtained.

The perineum was found practically intact. On vaginal
examination the uterus was found enlarged, apparently nor-
mally involuted, according to the history, and slightly retro-
posed. The cervix was slightly torn. The adnexa seemed
normal.

About an hour and a half later, the condition remaining
about the same in the meanwhile, the patient had another
very severe attack of vomiting, with great collapse and much
sweating, so that, in spite of stimulation and subcutaneous
infusion of normal salt solution, the pulse, which had fallen
to 60 to the minute and was very weak and intermittent,
gradually became weaker and finally ceased at the wrist, the
patient djdng shortly thereafter.

Blood. — An examination of a fresh blood specimen was
made about 9.30 A. M., February 13th, and found negative for
malarial organisms. Apparently a leucocytosis was present.

Urine. — Examination of a specimen obtained during the
night showed a distinct whitish flocculent precipitate, a dis-
tinct trace of albumin, no sugar, and no diazo-reaction.
Microscopically a number of hyaline and some epithelial and
pus casts, a number of pus cells and some ejjithelial cells, and
a number of micro-organisms, some of which showed mo-
tility, were found.

Uterine Culture. — Cover-glass specimens, stained with gen-
tian-violet, showed a few epithelial and some pus-cells, and
possibly an occasional coccus or in doubtful pairs, but so
few in number that it was impossible to say whether they
decolorized by Gram's method or not. Cultures taken on
bouillon, agar plates (2 dilutions), and anaerobic glucose
agar, all remained sterile.

The history pointing so clearly to puerperal infection, the
possibility of the gonorrhceal nature of the trouble was not
thought of, and, in consequence, no attempt was made to
obtain the gonococcus culturally from the uterus.

Patholociical Report.

Autopsy No. 1487, February 14th, 7.45 P. M., by Dr. W. G.
MacCallum.

Anatomical Diagnosis. — Acute vegetative and iilcerative
endocarditis, involving aortic, tricuspid and pulmonary
artery valves. Acute splenic tumor. Infarction of spleen.
Catarrhal cystitis. Puerperal uterus.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 120.

The l)otly is that of a young, wt'll-nourislied woman, whose
hreasts arc in tlie puerperal state.

Upon section, the peritoneal cavity is i'ound to contain
very little fluid, and the serous membrane is smooth and
glistening.

The pelvic cavity contains a small amount of a brownish,
slightly turbid fluid.

The omentum is bound down between the liver and spleen
by fresh adhesions over a small area.

The pericardium, upon being opened, contains a small
amount of feebly turbid fluid, Init its serous surfaces are
smooth and glossy.

The Heart. — Weight 325 grams. The epicardium is
smooth. The right auricle is normal. The foramen ovale
is open to the extent of 3 mm. The ductus Botalli persists
as a cord.

The tricuspid calve is delicate. Upon the posterior leaf,
alnitting upon tlio septum ventriculorum, is a large lobulated
vegetation which begins at the base of the valve and extends
to its edge, hanging into the intervalvular space on the
auricular surface of the valve. A granular mass also exists
behind the valve, between it and the septum and lying upon
the latter. Tlie leaflet lying to the left of this as the heart
is opened, shows a few minute pin-point translucent eleva-
tions on its auricular surface. The larger lobulated vege-
tations arc ojjnciue and yellowish and surmounted by soft
post-mortem clots.

The pulmonary artery valves- are delicate. At the junction
of the right and left leaflets are small translucent vegetations
on the ventricular surface.

The left aui-icle is normal.

The mitral valve is normal.

The aortic valves ure most extensively involved, the pos-
terior segment alone being free from vegetations. The loft
segment is surmounted on the ventricular side by a large
mass of lobulated vegetations which extend down on to the
ventricular wall. There is considerable roughening of tlie
endocardium of the ventricle below the right segment also.
The inner surfaces of these two segments in tlio sinuses of
Valsalva are roughened and covered by soft dark-colored
])ost-mortem clots. From the right sinus of Valsalva a probe
can be passed through an opening in the septum ventricu-
lorum into the vegetations on the ventricular side in the
right ventricle Ijeliind the tricuspid valve. This o])ening
has probably been caused by an extension of the iiillamma-
tion through the septum.

The heart muscle is rather soft and brown in color.

Measurements: Circumference of tricuspid valve, 12 cm.;
right ventricle, 8..5 X i cm.; circumference of mitral valve,
8 cm.; left ventricle, 7.5 X 12 cm.; circumference of aortic
valve, 7.5 cm.

The lunys present a moderate degree of (cdema; otlierwisc
they appear normal.

Spleen. Weight 300 grams. Measures 18 X 8 X G cm.

Excepting over two areas, one on the anterior surface

where the organ touches the liver, and the other at the
posterior edge, the spleen is quite smooth. Corresponding
to those areas of roughness the spleen is indurated and ele-
vated. The anterior area is adherent to the liver by fresh
adhesions, whilst over the posterior area are found a few
fibrous adhesions only.

On section, these elevated firm areas are found to present
the features of typical anajmic infarcts and are wedge-
shaped. The spleen is soft and light purple in color. The
great increase in bulk being in white spleen pulp. The
Malpighian bodies are greatly enlarged and jirominent, with
irregular margin.s, measuring 3 mm. in diameter. The
splenic Jiulp proper is not very greatly increased, but seems
very soft and siicculent.

The Liver. — AVeight 1000 grams. Surfaces are quite
smooth excepting where tlie organ is adherent to tlie spleen.

Gall-bladder and ducts are normal.

On section, it is soft and flabby and greasy to the touch.
The lobules are quite definitely marked out; the centers
being translucent, beyond them comes a congested zone, then
outside of it is a zone of pallor and yellow opacity.

The Kidneys. — Each w'eighs 175 grams, and in all respects
are alike apparently. They are slightly larger than normal,
and the capsules strip off readily. The stellate veins are
markedly injected, and between them the parenchyma has
a grayish look.

On section, the cortex is thickened and measures from
5-8 mm. The striations are fairly well marked. The
glomeruli are visible, but there is, however, some opacity and
an appearance of being much swollen in the labyrinthine
portion. The lines and dots of yellow opaque material are
quite noticeable. The pelves contain a thick ycllowisli fluid,
but they are not, however, especially injected.

The ureters are apparently normal.

The urinary Madder contains a small quantity of thick,
yellowish purifnrm fluid, and the mucosa is in places deeply
injected.

The iilcrus is enlarged and soft. The mucosa is some-
wliat congested, but there is no sign of intlaniuiation
(measurements of organ not given).

Fallopian tubes and ovaries are normal.

Ljanphatic glands are nowhere especially enlarged.

The lone-marroir (femur) is somewhat reddened.

Other organs and tissues appear normal.

MlCliOSCOrifAL EXAMIN-ATIOX OF TISSUES.

Heart muscle shows oedema and fragmentation (?).

Ltings also show general a'dema, leucocytosis in blood of
all vessels, and some local atelectasis.

Mammary //lands show evidences of lieing in the nornuil
state of lactation.

Spleen shows a slate of general enlargement. The ]ior-
tion containing llie infai'dion cmild not be found, li.ning
been inadvertently mislaid.

Liver presents evidences of chronic passive congestion
with fatty metamorphosis.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Kidneys. A laodcrato degi'eu of parenchymatous neph-
ritis is noted, accompanied by a few foci of small roiiud cells,
which also occur in the walls of the larger arteries.

Intestines exhibit simply post-mortem degeneration, and
evidences of leucoeytosis in their blood-vessels.

Fallopian Tiibes. Mucosa normal; blood-vessels give evi-
dence of a leucoeytosis.

Ulerus. Sections were cut from three sites: —

(a) Cervix (including part of vaginal portion).

(&) Body (], about the middle; 2, at the fundus).

These were stained in haimatoxylin and eosin, methylene
blue, by Weigert's and by Gram's methods.

(a) Cervix, on being stained in hematoxylin and eosin,
presented the following features: The vaginal portion gave
evidence of post-mortem degeneration only; likewise in the
lower part of the canal similar changes are found, and dense
masses of material staining blue in the haematoxylin can be
made out readily in small clefts in the disintegrated tissue,
being in all jDrobability bacteria.

The mucosa of the upper portion of the canal shows no
evidence of post-mortem change; it appears quite ragged and
adhering to it in places are masses of what seem to be
broken down red blood-corpuscles.

The submucosa is much richer in small round cells than is
normal, and scattered about in moderate numbers are phag-
ocytic cells containing altered blood jjigment. In places
where evidences of mucous glands exist, it is found that they
are choked with shed epithelium, at times retaining its
columnar form and at otliers being changed into granular
detritus staining well in eosin and showing much nuclear
debris.

Throughout the remainder of the section is noted a more
or less well developed degree of ccdema, best marked
towards the parts beneath the mucosa. This oedematous
fliiid contains large numbers of small round cells, a few
plasma cells, and moderate numbers of large mono- and
polymorphonuclear cells which frequently are seen loaded
with altered blood pigment, few in number and located
deeph^ in the lower portion of the section, but higher up
much more numerous and approach the mucosa, wJiere they
may be found lying in close contact to the deposits of
Ijroken down red blood-corpuscles.

The blood-vessels everywhere are greatly dilated and
show evidence of marked leucoeytosis, in which the poly-
morphonuclear cell prevails, but both large and small mono-
nuclear cells are by no means scarce.

The arteries show no signs of either peri- or eudarleritis,
but in some instances their walls are thickened, due to hy-
pertrophy of the muscular coat. Amongst the larger
arteries can be seen at times small, irregular areas of a
hyaline nature which slain Ijrightly with eosin. The vasa
vasorum give no evidence of inflammation.

The veins, especially along the course of the smaller ones,
show at their peripheries considerable small, round-cell
accompaniment.

Stained with methylene blue, the section presents no
definite signs of the existence of micro-organisms. Notable,
however, is the presence of numerous mast-zellen, more
numerous in the deeper portions of the section than in the
superficial parts.

Gram's stain, with Bismarck brown as counter-stain, sim-
ply brings out the presence of mast-zellen even more sharply
than with methylene blue, but presents no signs of bacteria.

Weigert's stain shows no bacteria to be present.

(&) Body of Uterus. — Stained in hsmatoxylin and eosin.

Mucosa much thinner than normal. Xo columnar epith-
elium found. Xo jjlacental tissue was noted. A few mu-
cous glands could be identified and were found filled with
shed columnar epithelium, mucus and some small round
cells.

The general condition is similar to that described under
cervix section, but, if anything, the small round cell infiltra-
tion is more intense, esjiecially between the muscle-bundles.

The arteries show the same hyaline masses and there is
no inflammation of the vasa vasorum. Occasionally seen in
section from fundus, but more noticeably in the section
from the middle portion of uterus, is a great thickening of
the adventitious coat of the larger arteries and so dense
that in places it resembles old dense hyalinized fibrous tissue.
In these arteries the lumina can scarcely be traced and, in
fact, a few show no lumina whatever, and their general
coiirse is a very tortuous one.

Sections stained in methylene blue. Gram's or Weigert's
stains, show no evidence of bacteria, but as before in cervical
sections, show jircsence of mast-zellen whose granules at
first glance might be mistaken for cocci.

Coverslip preparations were made from

(a) the valvular vegetations,

(b) the pericardial fluid,

(d) the pelvis of left kidney,

Xegative findings were recorded for (c), (c) and (d). Slips
from the vegetations showed the presence of large nmubers
of cocci, occurring singly, in pairs, in fours and in clusters;
also, in numerous proportion, the various kinds of leucocytes,
the polymorphonuclear ty])e greatly preponderating. The
cocci for the most part appeared lying free, but not infre-
quently they occurred within cells. Tyjiical biscuit-shaped
organisms were by no means the rule. They readily decol-
orized by Grani's method of staining.

The preparations from the urinary l)ladder exhibited sev-
eral varieties of bacilli and cocci, but of the latter none could

be said to resemble the gonoeoccus.

Cidtures. — Unavoidable necessity delayed the use of special
media for fifteen hours, but cultures in )ilain agar wei'e made
at once from

(a and /;) Aortic ami tricuspid vegetations.

(d) Heart's blood.
(c) Left kidney.

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 130.

(f) Urinary bladder.

These cultures were poured into Petri dishes and incu-
bated at 36.5° C. for 48 hours and then examined.

Results on plain agar:

(a) Aortic vegetations yielded the gonococcus, Strepto-
coccus pyogenes, Bacillus coli communis.

The isolation of the gonococcus on the plain agar was due
to its having developed ia a small fragment of blood-clot
which had been carried over in making the culture. It was
positively identified as such by its inability to grow on plain
agar or ox-blood serum, but growing luxuriantly upon hy-
drocele fluid agar, and finally by decolorizing in Gram's
stain.

(&) Tricuspid vegetation gave the above organisms with the
exception of the gonococcus.

(d) Heart's blood gave bacillus.

(e) Kidney was grossly contaminated by bac. subtilis.

(/) Urinary bladder yielded the Streptococcus pyogenes,
Bacillus coli communis.

Cultures in hydrocele fluid agar were made from

(a) and (b) Vegetations on aortic and tricuspid valves.

((') Splenic infarct.

These were incubated for 48 hours at 3G.5° C. and then
examined.

Three types of colonies were found, resembling those of
B. coli communis, Streptococcus pyogenes and gonococcus.
Transfers were made at once of the two former organisms to
plain agar-slants, and of the latter to hydrocele fluid agar
and plain agar-slants. Tj-pical growths of the colon-like
bacillus and of the streptococcus were obtained on the plain
agar^ and upon the hydrocele fluid agar isolated colonies
identical with those of gonococcus grew out. Strange to
relate, of flfteen plain agar-slants inoculated as checks from
the suspected gonococcus colonies, two showed slight but
definite growth of a scarcely perceptible nature, which, upon
examination, yielded a diplococcus identical in morpliology
and tinctorial reaction with the gonococcus. These two
growths were transferred again to plain agar and also to
h3'drocele fluid agar with the result that upon the latter
medium only did development occur, and further attempts
failed to produce growth from tliese liydrocele fluid cultures
upon plain agar.

This .eame result Dr. Young states has at rare intervals
come under liis notice also in tlie work of the genito-urinary
clinic.

That the third typo of organism isolated from these plates
was the gonococcus is proven by its failure to grow upon
plain agar (excepting tlie two instances noted beforehand)
and upon ox-blood scrum and other ordinary media, by its
being able to grow upon media containing human blood (as
noted on the plain agar plate) or human serum when grown
at 37° C, and by its inability to retain the stain when
treated by Gram's method.

Case 2.— Medical No. 9374. W. A., a^t. 28.

Was admitted to Ward F on November 25, 1898, beincr

sent in as a supposed case of typhoid fever. Patient com-
plained of pains in the stomach, heart and kidneys.

Family history was of no importance.

Past History. — As a child he had measles and possibly
typhoid fever. At 22 years of age he had an indefinite ill-
ness which was treated as smallpox, typhoid fever and diph-
theria, during the course of which there occurred a swelling
below the right ear which, on being opened, discharged pus.
There is an indefinite history of malaria following three
weeks after the above illness, which was cured by quinine.

Patient never had any urinary disturbances nor pains in
lumbar region. He had gonorrhoea three years ago, accom-
panied by an inguinal bubo which did not suppurate; there
were no other sequelae.

The patient denied syphilis; he was a moderate drinker.

Present illness began on September 2Gth. He partially re-
covered, but soon got worse again. He first noticed a gen-
eral weakness, and had " dumb chills " for three weeks daily,
followed by moderate sweats; there was neither nausea, nor
vomiting, nor herpes, nor diarrhcea. He then got steadily
worse and was confined to bed for 4-5 weeks. Improve-
ment followed so that he got out of bed and staid in his
room one week, then went about the house, but four days
later he had a relapse, which, the patient thinks, turned into
typhoid fever. This happened about a month ago; since
then he was in bed until two weeks ago, when he got up and
walked around, but owing to swelling of his legs and con-
sequent stifl'ncss, he returned to bed. In this period he had
herpes and night-sweats, although during the last three
weeks the latter have been absent; likewise he experienced
for the first time palpitation of the heart and shortness of
breath, accompanied by a rather bad cough, worse at night.
The expectoration is of a whitish color. Paroxysms of
coughing at times caused vomiting, chiefly at night and very
early in tlie morning.

The anlema of the logs has lasted two weeks and is no
worse than when it began upon ilie third day of this relapse.

Bowels are irregular, and there is some increased fre-
quency of micturition, especially at night.

Upon the day of admission (November 25th) he had chilly
sensations and his temperature rose to ]01.8°, falling to 97°
at 8 A. ir. on tlie 2Gth.

The ifliysical examination showed that patient was
ana'uiic, and a pufFy condition of eyelids was noticeable. The
pulse was of good volume but irregular in force and rliytlim.
with a suggestion of a collapsing quality. Rate 26 to quar-
ter minute. The heart was found to be enlarged, the point
of maximum impulse being in the fifth interspace, 8.5 cut.
from mid-sternal line. A thrill was felt.

Upon auscultation, at the base of lieart a short systolic
murmur was noted, traceable to the anterior axillary line.
Over body of heart a faint diastolic murmur was heard, be-
coming louder upon passing upwards and inwards. A fric-
tion rub was heard at the left of sternum in the second and
third interspaces, and in the same situation to tlie right of
sternum. At the aortic area a systolic murmur was quite

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

readily heard. Over the pulmouic area the heart-sounds
had a loud rumbling quality and the second sound was mark-
edly accentuated and reduplicated. The lungs showed the
presence of a few moist rales at the bases. The presence of
fluid in the abdominal cavity was made out. ffidema was
marked in the feet and legs. There was no general gland-
ular enlargement.

Upon the 30th he seemed more comfortable, but the car-
diac conditions became more pronounced and the lungs pre-
sented evidence of congestion. And upon the morning ol
December 1st he was cyanotic and drowsy and had an annoy-
ing cough. The heart and lungs presented nothing new.
ffidema was most noticeable in the tissues of face. Less
urine was voided. At 8 P. M. he said he felt comfortable,
but at 9.15 the nurse found him dead.

His blood was examined on day of admission and showed
htemoglobiu 18 per cent, leucocytes 8600, red blood-corpus-
cles 1,768,000. On the 28th of November the leucocytes
rose to 14,000, but upon the following day had fallen to 8000,
whilst htemoglobin rose to 31 per cent.

Examination of the urine on the day of admission pre-
sented the following condition: S. G. 1.013; reaction acid;
much albumin present; sugar absent; many epithelial casts,
pus-cells and small, round, nucleated cells present; a few
red blood-cells noticed. Diazo-reaction absent. Albumin
was present until the day of patient's death and was esti-
mated upon several occasions to vary from .8-1.3 per cent.

Abstract from the Pathological Eeport.

Anatomical Diagnosis. — Acute ulcerative endocarditis of
pulmonary valve; ascites; hydrothorax and hydropericar-
dium; acute splenic timior; small area of bronchopneumonia;
glonierulo-nephritis; simple goiter; Meckel's diverticulum.

Autopsy by Dr. MacCallum, December 3, 1898. No. 1208.
There was extensive oedema of the face, upper and lower ex-
tremities. The peritoneal cavity contained 600 cc. of
slightly turbid lluid. Both pleural cavities contained excess
of fluid.

The pericardial cavity contained about 200 cc. of a clear
fluid in which floated a few flakes of coagulated lymph. Ex-
cepting over the right auricle, the serosa was smooth and
glossy, here it was noticeably lustreless.

Heart. — Weight 400 grams. The right auricle and ven-
tricle contain firm post-mortem clot. The tricuspid valves
are delicate and competent. The pulmonary valves are the
seat of a most extensive ulcerative endocarditis, two of its
segments being almost completely destroyed, only tags witli
friable vegetations remaining; the third segment is better
preserved and carries on its free margin a soft, friable, rather
granular mass measuring 1 X 2J cm. x\ortic and mitral
valves normal.

Spleen weighs 800 grams and measures 23 X 13 X G cm.
The organ is greatly enlarged and is attached by a few fresh
slender adhesions to the body wall and stomach. Capsule
generally thickened, but to a moderate degree only. Upon
section the spleen is quite soft; color is dark purplish-red;

the trabeculae are well marked, and the ilalpighian bodies
are readily visible.

The kidneys are both alike. They are enlarged, weighing
together 470 grams and measuring 12| X 7 X -i^ cm. They
are engorged with blood, oedematous and show all the typical
signs of acute parenchymatous nephritis.

Bone-marrow of a femur is dark purple-red in color, soft
but not difiiuent.

Tlie thyroid gland shows a moderate degree of goiter.

Lymph-glands generally are enlarged and firm.

The other organs are either normal or have no bearing in
their pathological phenomena upon the special phase of dis-
ease under discussion.

Microscopic Examination.

Pulmonary Artery Valve. — One of the masses of vegeta-
tions examined shows that in its deeper parts it has been
quite completely organized, but in its more superficial parts
can be observed the presence of a dense mass of hyaline fibrin
with a capping of more delicately fibrillated fibrin; more
superficially are found small numbers of leucocytes.

The base of the valve is somewhat infiltrated.

Spleen shows great congestion. There is no evident in-
crease in the other tissues. There is no especial accumula-
tion of pigment.

Kidney section presents a few islands of connective tis-
sue of small extent in the cortex. There are accumulations
of small round cells about the blood-vessels and adjacent
tubules. The tubules are dilated, the epithelium is degen-
erated and hyaline casts are numerous; many tubules" con-
tain leucocytes which sometimes invade the casts. The
glomeruli are enlarged and completely fill the capsular
space, and show a marked increase in the cells contained
within the capillaries, and in some instances a fibrous thick-
ening of the capillary walls is observable.

Bone marrow presents an increase of lymphoid cells.
There is no fatty tissue evident.

Lymph-glands show an increase of polymorphonuclear
leucocytes and an increase of the endothelium of the sinuses,
with swelling of these cells.

Bacteriological Eeport.

At the time of autopsy cultures were made in plain agar,
as it was only upon the following day tliat a suspicion arose
of the possibility of gonorrhoeal infection and no hydrocele
fluid cultures were made. Tliis latter procedure was, how-
ever, resorted to later.

The cultures from the vegetations and other sources
proved negative on plain agar, excepting those from the
lung and peritoneal cavity, which yielded respectively the
Streptococcus pyogenes and the Staph3'lococcus pyogenes
albus.

Within 24 hours of the autopsy cultures were made from
the vegetations upon the valve in ascitic fluid agar, but upon
examination those proved to be unfit for working out on ac-
count of contamination.

JOHNS HOPKINS HOSPITAL BULLETIN.

[Xo. 120.

Coverslip preparations were made and examined from the
vegetations and from the nrethra. The former exhibited
nnmerous diplocoeci sometimes within cells or amongst cell
remains, but more often free. Their morphology corre-
sponded closel_y to that of the gonococcus and they decol-
orized in Gram's solution. The latter preparation presented
no definite micrococci.

Case 3.— Medical No. 9645. J. H. (colored), a^t. 22, was
admitted to the hospital npon March 9, 1899, complaining
of ])aiii and swelling in the right ankle.

Family history was negative.

ra»t Iliglorij. — In childhood he had lia<l uuunps, measles
and whooping-cough. He never had had rheumatism,
typhoid fever, diphtheria nor scarlet fever. He had pneu-
monia about four years ago. He has no urinary disturb-
ances, and denies gonorrhcea and syphilis, but admits ex-
posure to both.

He does not use alcohol or tobacco.

Present Illness. — One evening four weeks ago he com-
plained of soreness in the right ankle and next morning no-
ticed the region much swollen. Following this he had for
several nights chilly sensations and fever accompanied by
herpes labialis, but with no night-sweats. He was treated
outside for rhemnatism.

At the present he complains of aching in all bis limbs and
especially of pain in the right ankle, which causes him to
turn in bed with much difficulty. His ankle joint is swollen.

Phi/sical Examination. — Patient looks ill. There is no
cyanosis or herpes. Pressvire over femoral artery gave a
decided Corrigan impulse, and upon auscultation it gave a
pistol-shot sound.

The heart was found much enlarged, the point of maximum
impulse being in the fifth interspace 9 cm. from mid-sternal
line. There was no thrill present.

Upon auscultation at apex, a loud systolic murmur, trace-
able far out into the axilla, was heard; likewise a soft blow-
ing diastolic murmur. These could l)e traced readily up-
wards and inwards, and could lie heard at the aortic and
pulmonic areas and along both sternal borders. The
second pulmonic sound was relatively accentuated. Pulse
shows a fair volume and tension, collapses; rhythm regular
and is 2G to the quarter minute.

Liing showed ]iresence of a few coarse nlles.

Abdomen and organs negative.

No general glandular enlargement.

Genitalia negative.

Legs show no oedema, no nodes, no scars.

]i'ii/hl initlc is a little swollen, sensitive to pressure, shows
no efl'usion into joint.

Marcli Ifith, at midnight, vomiting set in ami patient com-
jilaiiK'd of al)dominal pain. Pulse small, feeble and rapid.
At 8 A. ]\r. his temperature, previously nornnil, was found to
be ]00.8'\ and the general condition improved considerably
over what it had been during the night. But at S.^5 he
died suddenly.

Blood E.raiii illation. — Leucocytes 55,000 upon day of ad-
mission.

Urine. — S. G. 1.011. H showed a few granular casts,
epithelial cells and detritus; otherwise it was negative.

Medical bacteriological report upon ilarch 9th proved that
the blood culture made was sterile.

Abstract from Pathological Eeport.

Autopsy by Dr. Flexner, ]\Iarch 11, 1899. No. 1306.

Anatomical Diaynosis. — Acute endocarditis, perforation
of aortic and mitral valves; purulent myocarditis; purulent
and liEemorrhagic pericarditis; chronic passive congestion of
the lungs; acute splenic tumor; anaemic infarction of spleen
and kidneys; acute nephritis; cloudy swelling of viscera.

No oedema present.

Area of jJcricardium uncovered by lung tissue measures
10 X 10 cm. Upon opening the pericardial sac there is an
accumulation of hauuorrhagic and purulent fluid about the
great vessels at the base of the heart in the dependent por-
tions of the sac dorsally. In all about 20 cm. of bloody
fluid, containing many floating grayish-white purulent
nnisses, can be obtained. The pericardial sac is adherent to
the pleural surface of the left lung. The visceral layer of
the pericardium is injected ; the surface opaque, and there
are yellowish adherent masses of fibrin and pus.

Heart weighs 400 grams.

The right and left auricles contain partially decolorized
post-mortem clot. The tricuspid and pulmonary artery
valves are apparently normal. The heart-wall is lax and the
fibers well separated, and the myocardium of left ventricle
shows pronounced fatty changes.

The aortic orifice above the valves measures 6 cm.

The Aortic Valve. — The right and middle segments of the
valve appear delicate, and the left segment is neither retract-
ed nor thickened, but has been perforated, apparently from
below, in that there is a communication just above the base
of the valve occupying the width of the right hemisphere
of the segment, and measuring about 3 mm. Through this
perforation there projects into the sinus of Valsalva a min-
gled red and white clot, tlie red poi'tion being soft, the white
dense and opafjne. This clot almost fills the sinus and con-
nects with a thruinlius located npon and within the acu'tic
segment of the mitral valve. This latter thrombus is situ-
ated upon the attached jiortion of the mitral valve, chietly
along the upper half. The valve has suffered a perforation
at its base, so that the thrombus protrudes into the cavity
of the left auricle. The endocardium of the left auricle
above the valve bulges into the auricular cavity over an area
4 cm. sq., its elevation being 2-3 mm. There is no percept-
ible change in the endocardium itself. Upon incision of this
diseased area one enters into a cavity in the substance of
the heart-wall, which communicates with the thrombus cov-
ering the aortic and mitral valves. This valve [cavity?]
contains necrotic and hiPmorrhagic material, and at the left
edge there is a distinct collection of pus. The cavity meas-

:\rAi;iii, iitiii.

JOHNS HOPKINS HOSPITAL BULLETIN.

ures 2i cm. in length nnd 1 c-ni. in depth: its walls are infil-
trated and firm.

The spleen is enlarged and weiglis -lOO grams. It has
no adhesions. Capsule delieate. In the mid-part of the
ventrienlar .surface is a pinkish infarction measuring
2 X li "-'ii'- "'• section, the organ show.s great increase ol'
sjilenic pulp, consistence is somewhat reduced and the ilal-
])ighian corpuscles are visible. The infarction, upon cutting
into it, is found to extend inwards for 1^ cm. into tlu' splenic
tissue; its consistence is firm.

The liver is congested and cloudy.

Ki(Iiicj/s. — The left one Is large. The capsule strips olf
easily. There is a single anaemic infarction about i cm. in
diameter, and lies quite superficially. Upon section the
cortex is swollen and opaque; the glomeruli are visible and
pink in color; striw are coarse. Thickness of cortex is 8 mm.
Eesistance is lessened and the organ is oedematous and pre-
sents small hemorrhages in the pelvic mucosa. The right
organ is the same in all respects as the left, except for a
larger ana?mic infarction, measuring 10 X 12 mm., and a
smaller one about the size of a hemp-seed. There are sev-
eral punctate luvmorrhages in the kidney substance. Com-
bined weight of kidneys is 400 grams.

The Riglit AnMe-joint. — The periarticular tiss\ies are ap-
parently normal, and the joint contains no excess of fluid.
and the synovial membrane is perfectly smooth.

The remaining organs present nothing of significance.

^IlCEOSCOI'ICAL Exam 1 NATION.

Tlii' lirarl-ijiiiscle is edematous.

The e])icardiuni is likewise cedematous and thickened,
showing an extensive proliferation of blood-vessels consti-
tuting a granulation tissue. Upon the surface of this tissue
are some remains of epithelium, and here and there a thin,
fibrinous deposit. Another section taken through the area
of suppuration contains a fibrinous coagulum with many
fragments of nuclei; underlying this is a loose granulation
tissue infiltrated with leucocytes.

(No sections were made through either of the affected
valves, as the heart was jireserved as a museum specimen.)

Spleen. — The organ is . gorged with blood which spreads
apart the splenic elements. One end of the section shows
an area of necrosis of splenic tissue sharjjly marked off by a
zone of hajmorrhage with a fibrinous network, inside which
is a bluish zone of fragmented nuclei of leucocytes.

Kidney. — Cells of tubules are disintegrated and ragged,
showing no nuclei. Some tubules are ]>acki'd with such des-
quamated cells.

The glomeruli show no extensive changes. There is no
increase of interstitial tissue anywhere.

There are extensive accumulations of polymorphonuclear
leucocytes found chiefly in the interstitial tissue, but often,
too, in the tubules. Occasional small masses of plasma and
round cells are seen in the medullary portions.

There is congestion of the capillary vessels.

Bacteriological Eepoet.

Kecogniziug the possible gouorrha-al origin of the heart
lesion, cultures were made upon what at the time was
thought to be human serum, as well as upon plain agar,
from the vegetations and infarcted areas of s^jleeu and kid-
ney. All endeavors to isolate the gonocoeeus failed, and
this may be ex})lained l)y the later discovery that by inad-
vertence ox-blood serum had been used instead of human
serum. From the agar-plates the following organisms were
isolated :

((/) Streptocucciis pyogenes from vegetations on aortic and
mitral valves, sinus of Valsalva, lung and renal infarct.

(b) Staphylococcus pyogenes aureus from vegetations on
aortic valve, sinus of Valsalva and lung.

(f) Bae. proteus vulgaris from vegetations on mitral valve
and sinus of Valsalva.

Cultures from heart's blood, liver, spleen, right ankle-joint
and pericardium proved sterile.

Coverslips were from the vegetations on aortic and mitral
valves, pericardial fluid, right ankle-joint, infarctions in
spleen and kidney. Examination showed that in the vegeta-
tions there could be seen large numbers of large diplococci
with some single or tetrad forms situated chiefly outside
of leucocytes, only scattered polymorphonuclear leucocytes
were found containing diplococci or groups of diplococci.
The organisms readily decolorized by Gram's method of
staining.

The pericardial fluid demonstrated the presence of vast
numbers of polymorphonuclear, lesser numbers of large
mononuclear and a few small mononuclear leucocytes,
amongst which, after very careful searching, could be found
a few polymorphonuclear cells containing small groups of
diplococci within their protoplasm. These diplococci were
larger than ordinary pus cocci, were biscuit-shaped and de-
colorized by Gram's method. Other coverslip preparations
proved negative.

With these statements prescnteil, it is clearly proven that
the flrst case is one of undouljted gonorrhceal origin. But
it must be conceded that in the two latter cases the lack
of clinical evidence of a recent gonorrhoea, and the failure
to demonstrate the presence of gonococci in culture rather
weakens the assumption of their being gonococcal in nature.

Yet from the demonstration on coverslip preparations
from the material of the valvular vegetations of micrococci,
coinciding in all respective non-cultural characteristics with
those of standard descriptions of the gonocoeeus, and, from
the peculiar massive formation of the vegetations them-
selves, we regard it as reasonable that both cases should,
without much doubt, be considered as examples of gonor-
rhceal endocarditis.

Discussion.

A review of the literature since the publieation of Thayer
& Lazear'.s article (.Journal of Experimental Jledioine, .Timnary,
1SS)0) shows the following' cases:

Scars (Medical & Surgical IJeports, Boston City Hosi^ital)
reports a case in which, following several attacks of gonor-

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 1-20.

rhoea, the last attack five months before, the patient, a man
aged 23, began to complain of pain in the back, stomach, and
limbs, which gradually became more severe. The temperature
was elevated from 99.5° F. to 105° F. Examination disclosed
a harsh systolic murmur over the pericardium. As the disease
progressed, the spleen became enlarged, and finally the pulse
irregular and weak with marked cyanosis present. Death
occurred on the seventh day after admission to the hospital.
Autopsy showed an ulcerative mitral endocarditis, with rupture
of the valve segments, infarcts in the left ventricle, spleen and
kidneys, and on bacteriological examination a coccus was
found quite generally distributed and unlike (he ordinary pus
cocci. No cultures were taken.

Sears also states that of a hundred and sixty-seven cases of
gonorrhoeal rheumatism admitted to the Boston City Hospital
between the years 1880 and 1897, twenty-five showed cardiac
murmurs to which no cause other than gonorrho-a was assign-
able.

Harhitz (Deutsch. med. Wochenschrift, 1899, XXV, pp. 131-134),
in a study of forty-three cases of infectious (i. e. caused by
organisms, streptococci, gonococci, etc.) endocarditis, found
two in which organisms decolorizing by Gram's method, re-
sembling gonococci in other respects, and not growing on the
ordinary media (agar, serum, bouillon, gelatin), were found on
the affected valves.

Jaccoiid, in a clinical lecture on gonorrhccal endocarditis
(Journal de Medecine Intern., Paris, 1900, IV, pp. 513, etc.),
mentions seventeen cases of gonorrhoeal endocarditis, his own
and those he has collected for two years, in which the diag-
nosis was confirmed at autopsy. In four of these gonococci
were found on coverslips from the valves, and in the remainder
the history pointed clearly to it and autopsj' showed ulcerative
endocarditis, though no mention is made of what was found
bacteriologically. In one of these oases gonococci were found
on the valves, and, moreover, the mjocardium was altered.

Karageos(/aiiz (Eshenedelnik, 1899, No. 46) reports the case of
a man, aged 34, who when first seen complained of epididj'mitis
and fever. Examination showed elevation of temperature,
anaemia, and a marked systolic murmur over the pericardium.
The heart was not enlarged. The spleen was enlarged, and,
towards the end of the disease, was four fingers' breadth below
the costal margin. The temperature was remittent in char-
acter, and there were chills and sweats. The patient had had
no disease previously, except intermittent fever. Two years
before he contracted gonorrhoea which had never been thor-
oughly cured, and occasionally showed exacerbations. Death
occurred after an illness of one month. Autopsy showed
friable yellowish vegetations of the aortic valve, with destruc-
tion of the valve segments. No bacteriological examination
was made.

Berg (Medical Record, April, 1899) reports the case of a man
who, after an attack of gonorrhcea, had involvement of the
metacarpo-phalangeal joint of the left thumb, accompanied by
chills and elevation of temperature. When first admitted the
patient gave evidence of an acute infection, with enlargement
of the spleen, but without cardiac involvement. During the
course of the disease, however, in which the symptoms became
progressively worse, chills, vomiting and finally convulsions,
supervening. Signs pointing to pyelo-nephritis and finally endo-
carditis at the mitral valve, set in, and death followed shortly
thereafter. During the course of the disease, repeated exami-
nations of the blood for malarial organisms and several Widal
reactions all proved negative.

Cultures from the blood were also taken twice during life,
in both instances proving negative.

Autopsy showed acute ulcerative endocarditis of two seg-
ments of the aortic valve with vegetations, two small vegeta-

tions on one of the flaps of the mitral valve, acute pyelo-
nephritis, acute splenic tumor with one small splenic infarct,
acute and chronic parenchymatous nejihi'itis.

Microscopically, diplococci, decolorizing by Gram, were found
in the vegetations from the aortic valve, and a few decolorizing
diplococci in the fiuid from the pelvis of the kidney. No cul-
tures were taken.

The following case is reported by Loeb (Deutschcs Archiv
fiir klinische Medicin, 1899, XXV, pp. 411-420). The patient, a
man aged forty-one, consulted him for swelling and pain in
the right fore-arm. Three weeks before he had had an urethral
discharge, but, with the exception of rheumatic pains in the
lower extremities, he had otherwise been healthy. During the
course of the trouble, which at this time was mild, pleurisy
and swelling of the ankle develoiied, and about two weeks
later cardiac signs and symptoms, consisting at first of a soft
systolic murmur, but shortly afterwards of loud blowing mur-
murs at all the cardiac orifices, with both systolic and diastolic
murmurs in the mitral area. Higher temperature, chills, and
enlargement of the spleen followed and were followed in turn
by signs of hypostatic pneumonia and adherent pericardium.
Death occurred shortly thereafter. At autopsy the layers of
the pericardium were found bound together by friable adhe-
sions. The left heart was somewhat dilated but not hyper-
trophied. Hard calcareous vegetations, attached to the pos-
terior and right anterior segments of the aortic valve, and
projecting into the ventricle, were found. The segments them-
selves were found thickened and perforated. The remaining
valves were unaffected.

The lungs were oedematous but showed no infarcts.

The spleen was enlarged and showed an infarct abdut the
size of a hazelnut.

The kidneys showed change, and there was a small red in-
farct in the right.

The bladder was negative.

From the vegetations on the affected valve large numbers of
diplococci, morphologically similar to gonococci, and decoloriz-
ing by Gram's method, were found. Bacteriological examina-
tion of the affected synovial sacs and joints and the sidenic
infarct were negative. No cultures were taken.

A most interesting case is reported by Bjelogolowij (Bol-
nitche Gazette, Bolkina, January, 1899, No. 4). The patient, a
man aged 32, without history of inflammatory rheumatism or
other disease except syphilis, was admitted complaining of
palpitation and weakness of the heart and swelling of the
right testicle, following gonorrhcea of one and one-half months'
duration. According to the history the cardiac trouble had
come on about two weeks before, and the epididymitis, which
it proved to be, was of only a few days' standing.

On physical examination cardiac dulness was found some-
what increased, and at the apex two well-marked murmurs
were heard, both being well transmitted. The pulse was col-
lapsing in quality.

Course.- — At first the course of the disease was mild, but after
several days chills, fevers, sweats, with weakness, vomiting,
diarrhoea, pericardial pain and enlargement of the spleen came
on, ending finally in the patient's death in collapse.

Autopsy. Anatomical Diagnosis. — Verrucose endocarditis of the
tricuspid valve; ulcerative endocarditis of the aortic valve;
catarrhal iineumonia; chronic hyperj^lasia of the spleen;
ha?morrhagic infarcts of the spleen; cyanotic induration of the
liver; hfemorrhagic infarction of the kidneys; catarrhal colitis;
catarrhal enteritis.

Heart. — The pericardium contained several tablespoonfuls
of a serous, transparent, yellow fluid. Fibrinous blood-clots
were present and a little fluid blood. The walls were pale, of
a graj'-red color and looked normal. On the xipper surface of

MAKCir, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

the tricuspid valve there were several soft, vi'art-like excre-
scences, of a reddish color, and about the size of a g:rain of
corn.

The two posterior cusjjs of tlie aortic valve were fused, dis-
figured and tliickened with yellowish excrescences, which were
covered on the surface with a friable and readily removable
mass. The sinuses of Valsalva were dilated. The right cusp
had a perforation the size of a goose-quill, filled with a bloody,
fibrinous clot.

The mitral valve was normal.

Lungs. — Fibrinous pleurisy was present. Lungs otherwise
negative save for a broncho-pneumonia at base.

Spleen. — Double its nornuil size, dark-colored, dense, tra-
beculse well marked, and presenting on the lower aspect at the
edges a hajinorrhagic infarct the size of a hazelnut.

Liver. — Normal, yellowish-red color, fidl-blooded.

Kidneys. — Large, cai)sules strip with difficulty; the cortical
layer of each kidney thickened and contains a discolored
hcemoi-rhagic infarct the size of a pea. The tissue is darker
than normal and there is pus present in the pelvis of each
kidney.

The mucosa of the bladder, beyond being pale, seemed
normal.

The stomach and intestines were normal save for a catarrhal
colitis.

The knee and ankle joints .showed no change.

Phimosis was present. From the fossa navicularis a small
drop of pus was expressed.

The testicles were without apparent change.

During life examinalion of the blood was made in the follow-
ing waj's with these results:

1. Slide of blood, stained with methylene-bhu' and ensin,
showed apparently diplocoeci, but this is doubtful.

2. A small drop of blood from the finger planted on gelatin
and peptone-agar gave no growth.

3. One cc. of blood was obtained, under aseptic precautions,
from the vein at the elbow, and three plates, consisting of
two-thirds glycerin-agar and one-third hydrocele fluid, were
successively inoculated.

After forty-eight hours over twenty whitish, punctate col-
onies developed on the three plates. In some -of these a darker
center was noticed.

Microscopically, diplocoeci, resembling gonococci and decol-
orizing by Gram, were found.

Transplantation on gelatiii-agar and on bouillon gave nega-
tive results.

Transplantation on an h3drocele-agar slant gave a slowly
developing, beautiful growth, resembling that of the gono-
coccus in all respects, and proving the presence of gonococci
in pure culture in the blood.

After death bacteriological examination gave the following
results:

1. About twenty-four hours after death culture from the
heart's blood made on hydrocele-agar gave negative result.

2. Tubes of agar, bouillon, gelatin .■inil hydrocele-pepton-
glycerine-agar were inoculated with material obtained from
the vegetations of the aortic valve; all with negative result.

3. Microscopical examination of the material from the vege-
tations of the aortic valve showed, however, diplocoeci com-
pletely identical with those found during life in the blood.
These occurred both intracellular and extracellular, and de-
colorized by Gram.

4. No organisms were found microscopically on section of
the splenic infarct.

Note Since the foregoing article has gone to press, a fourth case has

come under our notice in the Pathological Laboratory.

Autopsy No. 10:^0 There was a clear clinical history of an acute

gonorrha'al urethritis, for which the patient had come to the dispensary
for treatment. At the end o£ a week he disapiieared, but returned in
three months complaining of having had rheumatism of the joints, and
pains in the chest and feeling generally unwell. He was at once admitted
to the hospital under Dr. Osier's care, where his heart was found to be
seriously involved. He died that night.

The autopsy showed an acute ulcerative endocarditis of the aortic
valve, similar in character to that mentioned in Cases II and III. In
coverslip preparations made from the vegetations micrococci were found
having all the characteristics, morpho'logically and tinctorially, of
Neisser's gonocoecus. Owing to an unavoidable lapse of time and to
over-much handling of the heart, cultures proved an absolute failure on
account of resulting contamination.

N. MacL. H.
W. M. D.

AN EXPERIMENTAL STUDY CONCERNING THE RELATION WHICH THE PROSTATE GLAND BEARS
TO THE FECUNDATIVE POWER OF THE SPERMATIC FLUID.

By George Walker, M. D.,
Instructor in Suryery, Johns EopUns University.

In order to eliicidttte more clearly the connection which
the prostate gland holds to fertilization, I have instituted a
series of experiments in which the gland in white rats was
excised in part and in whole, and its effects on fecundity
noted.

Steinach, in a series of investigations made to determine
the function of the seminal vesicles, found that by an exci-
sion of them the breeding property was reduced about one-
half. When both pro.state and vesicles were removed, it
was brought down to nil. lie did not excise the prostate
gland alone, nnd could tluTfl'ore adduce no proof as to the
part it played.

Eats were selected on account of the ease with which
the gland could be removed, and also from the minimum
amount of danger of injuring the seminal ducts; the two
being in rodents quite distinct, and not connected. The
gland consists of four, or sometimes six, distinct lobes; the
two anterior ones are very much larger than the others;
are pear-shaped, and stand well up and away from the
urethra, being held by a fascia connected with the bladder.
They communicate with the urethra by several small ducts
whicli ein])ty into Iho roof of the Uunen just in front of the
vesicle neck. The posterior lobes are somewhat triangular
in shape, are more closely connected with the urethra, and

JOHNS HOPKINS HOSPITAL BULLP]TIN.

[No. UO.

are very mncli smaller and flatter, forming alimit onc-fonrlh
of the whole gland. They extend slightly around the
ejaeulal(ii-y ducts, and well up on the side of the ui-clhra.
The two lateral lobes are only occasionally })resent, and seem
to be developed from the posterior ones. A second glandular
substance is connected with the inner side of the seminal
vesicles, and presents the same macroscopic aj)pearance as
does the prostate; Init on microscopic section it is shown to
be a strui-ture similar to that of the vesicles.

The excision of the glands was done thus: The animals
were etherized, the aljdominal wall was carefully sliaved and
cleansed, and an incision made in the median line. This
brought the anterior lobes into view, and by gently pulling
the bladder forward and upward, they could very plainly
be seen. They were very carefully separated from the lilad-
der and from each other; a ligature was thrown around each,
near the urethra, and both lobes excised; the posterior ones
were exposed by pulling the bladder and seminal vesicles
over the pid)es; they were then very carefully separated
from the surrounding structures and teased by a pair of small
forceps from their connection with the urethra. This occa-
sioned only slight bleeding, which soon ceased without a
ligature. The abdomen was closed by interru])ted silk
sutures, the skin in the same manner, and the wound dressed
with cotton and collodion. The animals usually made a
rapid recovery, and appeared very lively on the following
day.

The rats selected for ojteration were full grown, well
de\eliiped, and in good physical condition. In several series
the two anterior lobes were excised, and the effect on pro-
creation noii'd. In the other series, all of the gland was
removed, and the result also recorded.

The first series consisted of seven pairs; these were mated,
and the number in the litter carefully noted. The two an-
terior lobes were then removed, and after sufficient recovery
they were again mated.

Pair No. 1. Mated July 10th. Five w-eeks later the fe-
male gave birth to eight young; anterior lobes excised, and
after recovery again mated Angust 23d; September 15th, a
litter of eight was found.

Pair No. 2. Previously mated, and gave birth to ten
young; two anterior lobes removed, and second mating
August 24th. After two months, negative result.

Pair No. 3. Previously mated; five young. Anterior
lobes excised and paired August loth. Six weeks afterwards,
four young.

Pair No. 4.. Previously mated; eight young; removal of
anterior lobes, and mated August 18th; after seven weeks,
two young.

Pair No. 5. Previously mated; seven young. Anterior
lobes excised, and second mating August 21st; after seven
weeks, eight young.

Pair No. 6. Previously mated; eight young; anterior
lobes excised, and mated second time August 23d; negative
result.

Pair No. 7. Previous mating resulted in eight young;

removal of anterior lobes; second mating yVugust 30tli; neg-
ative result.

From ihc above it is seen that in two })airs the breeding
was normal; in two others the nundicr was reduced to two
in one case, and to four in the other, while in the remaining
three the result was entirely negative.

A second series of fifteen pairs was taken; no jirevious
mating, however, being done, as it had been ascertained by
watching several other series that rats are fertile in nearly
every instance. As in the preceding series, only the anterior
lobes were removed ; after complete recovery they were
paired with the females.

Pair No. 1. Positive result after five weeks; eight young.

Pair No. 2. Positive result after six weeks; seven young.

Pair No. 3. Positive result after six weeks; eight young.

Pair No. 4. I'ositive result after five weeks; five young.

Pair No. 5. Positive result after eight weeks; ten young.

Pair No. G. Positive result after nine weeks; eight young.

Pair No. 7. Positive result after four weeks; six young.

Pair No. S. Positive result after six weeks; seven young.

Pair No. !). Positive result after five weeks;' five young.

Pair No. 10. Negative result after three months and
twenty-five days.

Pair No. 11. Negative result after three monllis and
twenty-five days.

Pair No. 12. Negative result after three nuuiths and
twenty-five days.

Pair No. 13. Negative result after three months and
twenty-five days.

Pair No. 14. Negative result after three months and
twenty-five days.

Pair No. 15. Negative result after three months and
twenty-five days.

Afterwards tin" males were killed, and the seat of excision
examined. In three of the fertile ones it could be seen that
a small amount of the anterior lobes had been left, while in
the others it had all apparently been taken away. In the
ones which had proved unfertile, there was no part of the
anterior portion present. In quite a number of them, and
most notably marked in the ones which had proved fertile,
the posterior lobe had increased in size. In the negative
ones no such increase in size was apparent.

A third series of animals was selected and mated before
operation. The ones which bred were chosen for the ex-
cision of the gland. At the first oper&tion only the anterior
lobes were removed; they were again mated, and the fertile
ones selected and subjected to a second operation in which
all of the gland was taken away. The result is as follows:

Pair No. 1. Mated before operation; bred five. March 1st,
removal of anterior lobes. Second mating March 5th.
April 10th, bred three. April 12th, removal of the remain-
ing gland; again mated; negative resiilt.

Pair No. 2. Previous to operation bred eight; removal
anterior lobes March 1st; mated March 4th; negative result.
Second opcralinn, entire removal April loili; negative
result.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Pair No. 3. Before operation bred four. First opera-
tion February ISth; mated March 3d. April 3d, bred seven.
Second operation April 2-lth; entire removal. Mated
April 26th; negative result.

Pair No. 4. Before operation bred seven; operation, re-
moval anterior lobes March 1st; mated March 3d; April
22d, bred four. Complete removal April 2-4th; mated April'
2Gth. After six weeks, positive result; bred six.

Pair No. 5. Before operation bred six; removal anterior
lobes March 1st; mated March 3d; April 15, bred six. Sec-
ond operation May 7th; complete removal; negative result.

In the above series, four out of the five were fertile after
the first operation; number two being negative after the first
and after the second. In two the number was normal, but
in the remaining two pairs, the number was decreased in one
case from five to three, and in the other from seven to four.
In one pair, however, number three, it was increased from
four to seven. After the second operation, four out of the
five were sterile, only one bred.

The autopsies showed in the four barren ones that the
gland had been entirely removed, whereas in the fertile ones,
about three-fourths of the posterior lobes had not been ex-
cised.

In order to determine whether the seminal ducts had been
injured during operation, and thus had prevented the out-
flow of the seminal fluid, a careful examination of both ori-
fices and canals was made; they were found in each instance
to be patent; moreover, on gently squeezing the seminal
vesicles the secretion freely oozed through the orifices, and
on stripping the vasa deferentia, the secretion freely exuded
from the openings. The fluids thus obtained were examined
microscojjically and found to contain spermatozoa.

A fourth series of eleven pairs was selected, and the en-
tire gland removed at one sitting. These, after recovery,
were mated, with the result below recorded. It should be
noted that the females had been kept for a long time sepa-
rate, so that it was made sure that no fertilization was
present.

After sufficient length of time proved nega-

Negative.
Negative.
Negative.
Negative.
Negative.
Negative.
Negative.

After six weeks, positive result; three young.
After seven weeks, two young.
After five weeks, five young.
It will thus be seen that in the eleven cases, eight were
entirely negative, and in the remaining three, there was not
a full litter in any instance; five being the nearest approach
to it; in the other two the litter being two and three re-
spectively.

The autopsies of Nos. 1, 2, 3, 4, 5 and G, showed a com-

Pair No.

S).

Pair No.

10.

Pair No.

11.

plete removal of the gland; No. 7 presented a small piece
of the lateral lobe; No. 8 showed only a slight trace of the
left lobe; No. 9 showed fully three-fourths of the posterior
lobes present, and a moderately sized stump of the anterior
ones; in No. 10 there was found a large lateral lobe which
had not been excised. In No. 11, although a positive result
was obtained, there was apparently no gland left, either pos-
terior or anterior. This last case was the only example in
the whole series in which the male had proved fertile with
no portion of the gland remaining.

The examinations proved that in most of the negative pairs
there had been a complete removal of the gland; in two
eases, however, some of it was present, while in the fertile
ones, two presented large remnants of the gland which had
failed to be excised; in one instance, all had apparently been
removed. A similar examination as to the patency of the
seminal ducts was made, and in only one instance was an
occlusion found, and in that it was in only one duct. The
others were perfectly open, and emitted their secretion.

The sexual desire and capacity of the rats were carefully
noted both in those in which a partial excision, and in those
in which a complete excision had been done. The exam-
ination was made by carefully watching them for some time
each day after they were mated, subsequent to the operation.
In every instance, the males were as sexually active after
the operation as before; and in no instance was the capacity
diminished.

The animals in which a complete removal of the prostate
gland had been done were kept from four to seven months
after the operation in order to ascertain whether any effect
had been produced on the testes by the removal of the gland.
At the end of this time the animals were killed with chlor-
oform, and the organs carefully removed and examined. In
every instance they were of normal size, of natural consist-
ency, and in no way did they differ from the usual type.
They were preserved in Zenker's fluid, and the subsequent
microscopic sections did not reveal any changes.

In order to determine whether any effect was produced in
the development of the testes by a very early removal of the
prostate gland, I selected a certain number of young and
healthy males, just at the age when the gland was beginning
to develop; another series of about the same age being kept
as controls. The prostate glands in the first number were
entirely excised; the animals were kept for nearly six months,
by which time they were thoroughly grown. They were
then killed, and the testes upon examination were found to
have developed normally; and they presented the same ap-
jiearance and feel as were present in the other series of rats
which were kept as controls. These were also examined
microscojiically, and no difference was found in them. The
seat of the ojieration was examined; in one there had been a
partial development of the gland; in the others no trace of it
was discernible.

SUJIMART.

First series of seven pairs; anterior lobes excised; two
bred normally, two had small litters, two were negative.

JOHNS HOPKINS HOSPITxlL BULLETIN.

[No. 120.

Series No. 2. Fifteen jjairs; anterior lobes removed; nine
bred normally, five proved negative, one escaped.

Series No. 3. Five pairs; after first operation, removal of
anterior lobes; four out of five bred normally; one was nega-
tive. After a second operation wliere complete removal was
done, one bred normally, four were negative.

Series No. 4. Eleven pairs; complete removal of the gland
at one sitting; eignt were negative, three had small litters;
none positive.

Series No. 5. Prostate gland removed in early life, did
not have any effect on the subsequent development of the
testes.

Conclusions.

From the above experiments, the following conclusions
can safely be drawn:

First. That a removal of the anterior lobes of the pros-
tate gland in rats has no effect on breeding; but in a certain
number it diminishes the fecundating power; and in a few
it is destroyed entirely.

Second. Complete excision has a very marked effect on
fecundity, reducing it to almost nil when the gland is en-
•tirely removed.

Third. Partial or complete removal of the prostate
has no effect upon the sexual desire and capacity.

Fourth. Complete removal of the gland in the adult
animal has no effect on the liistological structure of the
testicles. Complete removal of the prostate in the young
animal has no effect upon the subsequent development of
the testes.

SUMMARIES OK TITLES OF PAPERS BY MEMBERS OF THE HOSPITAL AND MEDICAL SCHOOL
STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.

Charles Russell Baedeen, M. D. Casto-Vertebral Varia-
tion in Man. — Anatomischer Anzeiger, November 7, 1000.

Simon Flexner, M. D. Nature and Distribution of the New
Tissue in Cirrhosis of the Tjiver (Preliminary Cnntmuni-
cation). — Proceedings of Ihe Pallwlogical Sorieiij of Philu-
delphia, November, 1900.

William Osler, M. D. An Address on John Locke as a
Physician. — Lancet, London, October 20, 1900.

Howard A. Kelly, M. D. A Eapid and Simple Operation
for Gail-Stones Found by Exploring the Abdomen in
the Course of a Lower Abdominal Operation. — Ulediral
Neil's, December 22, 1900.

Henry J. Berkley, M. D. Clinical Cases. VIL The
Pathology of Chronic Alcoholism. — The Ainericaii Jour-
nal of Insaniiij, January, 1901

FURTHER OBSERVATIONS ON EPINEPHRIN.

By John J. Abel, M. D.,

Professor of Phaniiaruloij!/. Johns Ilophins Unirersifi/.

Shortly after tlie publication of my last paper on e[)i-
nephrin,' I began to try simpler methods for the isolation of
this substance, methods which sliould avoid the process dl
benzoating and the subsequent liydrolysis in the autoclave.
Although the highly active bisulphate that was secured by
these simpler methods was considerably contaminated with
cholin and witli compounds of the xanthin series, these at-
tempts nevertheless taught me that the autoclave product as
formerly described differs in several important particulars
from that obtained without benzoating or subsequent hydrol-
ysis. The latter product, which I might term unaltered or
native epinephrin, is not precipitated by ammonia and fails
to give many of the alkaloidal reactions which are charac-
teristic of the autoclave product.

At first glance it might appear tliat the epinephrin hitherto
described by me was a mixture of two different substances,
one of which is precipitable by ammonia: the other, a jijiysin-

' Zeitschr. f. pbysiol. CUcm., B:l. xxviii, 3. ."IS.

logically active, pyrocatechin-like substance, not possessing
this projierty: and this is in fact the view taken by v. Fiirth "
in a ]iaper in whicli he comments on my results. This author,
using a modification of the earlier methods of Holm' and
Krukciilierg ' ju'ecipitates opiiu'iibrin with ammonia and a
lead or zinc solution, suspends t.he resulting ju'ccipitate in
methyl alcohol and decomposes it with concentrated sul-
phuric acid.

In fliis way he obtains a methyl-alcohol solution of a
sulphate which has not been subjected to hydrolysis, and since
it differs in several important particulars from epinephrin as
described by me, he concludes (hat we are dealing with two
different substances. He considers the term epinephrin to be
applicable to a substance that is physiologically inactive, pre-
cipitable by ammonia, devoid of chromogenic properties, in-
capable of reducing silver nitrate or of forming a compound

'Zeitsclir. f. ph}-siol. Cbem., Bd. xxix, s. 10.5.
3 Journ. f. pract. Chemie, Bd. c (18C7), s. 1.50.
* Vircliow's Arcliiv, Bd. ci (18S.5), s. 543.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

with ferric chloride, while he applies the name suprarenin to
the well known chromogen or physiologically active substance
which in its native condition is non-precipitable by ammonia,
reduces silver nitrate, yields an iron compound of specific
qualities, fails to give a series of alkaloidal reactions charac-
teristic of hydrolyzed epinephrin, and on fusion with potas-
sium hydrate yields no odor of indol or skatol. Such, in
brief, according to v. Fiirth, are the main characteristics of
what he calls two different substances.

I propose in this paper to take up the main points pre-
sented by V. Fiirth and I hope to show that differences of
method are alone responsible for the variations he has noted.
What V. Fiirth calls suprarenin is native or unaltered epi-
nephrin.

I. Precipitation by Ammonia.

Epinephrin obtained by hydrolyzing its benzoyl compound
is precipitable from an aqueous solution by ammonia in the
form of yelluwish-white flocks which rapidly darken on ex-
posure to the air and which are physiologically inactive.
And here it may be remarked that complete precipitation of
a salt of epinephrin is attended with some difficulty. The
fractional method must be used in order to avoid an excess
of ammonia, and toward the end of the operation, when only
a little of the chromogenic substance remains, it is necessary
to concentrate the solution with the help of the vacuum des-
iccator before the final precipitation is made. The various
precipitates may be washed with ice-water, although it must
be borne in mind that prolonged washing will dissolve almost
all of the fiocculent precipitate with the exception of a small
amount of a dark insoluble residue which has become oxidized
by long exposure to the air. When the fractional precipita-
tion has been properly conducted the final filtrate from a
solution of epinephrin bisulphate, for example, will contain
nothing but ammonium sulphate, while on the various filters
will be found all of the chromogenic substance.

Now, epinephrin, the chromogenic substance of the supra-
renal gland, whether isolated by v. Fiirth's or any other
method that does not involve hydrolytic treatment, becomes
immediately precipitable by ammonia as soon as such hydro-
lytic treatment is applied. Proof for this statement is found
in the following facts:

1. The iron compound of " suprarenin " was prepared ac-
cording to V. Fiirth's method, which I consider a distinct
contribution to our knowledge of the subject. His directions
were followed with the exception that the compound was
redissolved and reprecipitated out of acidulated methyl alco-
hol in order to remove as far as possible impurities that might
be present. I then made benzoyl and acetyl epinephrin from
this iron compound, and on saponifying these derivatives in
the autoclave, I found that the resulting solutions yielded
fiocculent, inactive epinephrin on the addition of ammonia;
in other words, they behaved exactly like compounds of the
same name formerly described by me.

2. By cautiously adding ammonia to the methyl alcohol
solution from which v. Fiirth prepares his iron compoimd.
I removed all excess of sulphuric acid and then drove off the

methyl alcohol in the water bath. The residue was now taken
up in water, filtered and heated in the autoclave for two
hours in the presence of a little sulphuric acid and under a
pressure of four atmospheres. The solution, which at first
gave no precipitate with ammonia, now yielded an abundant
fiocculent preci^^itate on the addition of this reagent. Fur-
thermore, I dissolved the iron compound in methyl alcohol
containing a little acetic acid and removed the iron by re-
peated treatment with hydrogen sulphide. After evaporation
of the methyl alcohol the residue was taken up in water, a
little dilute sulphuric acid was added and this solution was
hydrolyzed as before. Here again, the same result was ob-
tained. The solution, which before treatment in the auto-
clave gave no precipitate with ammonia, now yielded epi-
nephrin in abundance.

3. It might be asserted that the above facts are capable
of another interpretation, that the substance which on hydrol-
ysis yields this fiocculent precipitate is not the chromogenic
substance of the siiprarenal capsule but an entirely different
body which on precipitation drags down the chromogenic
substance with it; that it is in fact merely present in v. Fiirth's
iron compound as an impurity. But my experiments with
the active bisulphate of epinephrin, which can be converted
quantitatively into this fiocculent substance (barring small
losses by conversion through oxidation into an insoluble
form), fully prove that a separation of this body into a chro-
mogenic and a non-ehromogenic substance is impossible. It
is itself, as stated in my earlier papers, an inactive modifica-
tion of the active substance of the suprarenal gland. A
further proof of this assertion is seen in the following: A
chemist in the employ of one of our manufacturing firms has
recently sent me about 1-10 of a gram of a micro-crystalline
compound derived from the suprarenal gland that possessed
a high degree of physiological activity and gave all the specific
reactions of the native non-hydrolyzed form of the active
principle. The method of its manufacture has not been made
public and I have not as yet determined whether the com-
pound represents the free base itself or some crystalline
derivative.

This compound, which dissolves only sparingly in cold
water, also fails to give a precipitate with ammonia unless
subjected to treatment in the autoclave, behaving, therefore,
like all specimens of the chromogen thus far isolated.

In short, it is an inherent property of the active principle
of the suprarenal gland, prepared by whatever method, to
fall out in the form of a fiocculent, physiologically inactive
precipitate on the addition of ammonia after previous treat-
ment in the autoclave.

It is not surprising that v. Fiirth should have failed to
note this property of epinephrin inasmuch as he did not test
any of my compounds as made by saponification of the ben-
j zoyl derivative, in respect to their preeipitability by ammonia,
' but applied this test only to solutions obtained by decom-
; posing his ammoniaeal lead on ammoniacal zinc precipitates.
j The substance obtained by him from these solutions on the
addition of annnonia is not epinephrin; it is either some de-

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 120.

generate product of it or an entirely different substance. His
observation that tiie active principle in its native state is not
precipitable by ammonia is, however, entirely correct.

II. On the Ihon Compound of Epinephrin.

Now that it has been shown that some of the properties of
epinephrin, as heretofore described, are not inherent in the
native substance but are developed by chemical manipulation,
it is of -interest to inquire into the behavior of its two chief
modifications toward iron salts.

As before stated, v. Fiirth has shown that a solution of the
active I'rinciple in methyl alcohol yields a highly active pre-
cipitate on the addition of ferric chloride and ammonia, aud
that the addition of ferric chloride to a dilute aqueous solu-
tion containing a little acid gives a bright green color, while
if the solution is alkaline, a carmine red color is the result.

Up to this time no analyses of this iron compound or of
its derivatives have been given, nor are we informed whether
its iron content varies on re-solution and re-precipitation,
nor how far variability in this respect is affected by dilferent
modes of manipulation.

This author also appears to believe that the salts of
epinephrin described in my previous papers are incapable of
yielding an iron compoimd except as the chromogen is pres-
ent as an impurity. But the experiments presently to be
described show that epinephrin bisvilphate is quantitatively
convertible into an iron compound indistinguishable in ap-
pearance and chemical reactions from that described by v.
Fiirth, although differing in two respects from his compound:
first, in that it can be precipitated directly from an acidu-
lated aqueous solution of epinephrin, and second, that it is
physiologically inactive. These differences, however, like
others already alluded to, are due solely to differences in
previous manipulation; in short, the conditions here are the
same as in the ease of the precipitation by ammonia, for if
the methyl-alcohol solution from which v. Fiirth derives his
iron compound be taken and the methyl alcohol expelled, the
residue dissolved in water, acidulated with a little dilute
sulphuric acid and treated in the autoclave as already de-
scribed, a transformation into what I have hitherto called
epinephrin will be formd to have occurred.

After removal from the autoclave the solution still pos-
sesses a high degree of physiological activity, but the addition
of ferric chloride and ammonia now yields a precipitate, the
iron compound of epinephrin, which is physiologically inac-
tive. Here, too, the hydrolytic action of the autoclave is
responsible for an inactive form of the iron compound, capa-
ble of precipitation out of acidulated aqueous solutions of
the active principle.

conversion of epinephrin bisulph.\te into an iron
compound.

The following experiment was made with 1.197 grams of
pure epinephrin bisulphate, another portion of which had
served as the source of the phenylcarbamic di-ester of epi-

nephrin described by me in an earlier paper." The salt was
dissolved in very dilute sulphuric acid, and ammonia was
cautiously added until about two-thirds of the epineplirin was
precipitated in two fractions in the form of yellowish-white
flocks. These were repeatedly wa.shed with ice water and the
washings were added to the original filtrates. The flocculent
precipitates were now separately dissolved in very dilute sul-
phuric acid and converted into an iron compound by the
addition of ferric chloride and the siibsequent addition of
ammonia to very near the neutral point.

These jirecipitates were repeatedly washed by sedimenta-
tion in tall cylinders until the ammonium sulphate was en-
tirely removed.

The compound was then redissolved in dilute sulphuric
acid, reprecipitated with ammonia and washed as before, col-
lected on a filter and dried over sulphuric acid.

The filtrates from the precipitations by ammonia together
with the washings were also converted into the iron com-
pound, which, after being washed in a tall cylinder by sedi-
mentation, was redissolved in very dilute sulpluiric acid,
reprecipitated by ammonia and washed till all traces of sul-
phuric acid had disappeared.

In this connection it may be remarked tliat the washing
of the iron compound as above described until it is free from
ammonium sulphate aud sulphuric acid is accomplished with
difficulty. Large quantities of water are required and the
amoimt of the iron compound which remains in solution in
the supernatant fluids depends of course upon the reaction
of these fluids. This reaction, I may remark, is difficult to
maintain at the same level in the several cases. Usually the
wash fluids were colorless, but even then the addition of
ammonia caused a farther precipitation of the iron com-
pound. It is to be noted, also, that the iron content of the
compound here considered varies with the conditions of its
precipitation. Thus, if the iron content of a given fraction
is 8.50,'^, that precipitated from its washings may be as high
as 12.62;^, or even higher, and this same variability is met
with if the portion on the filter is redissolved and reprecipi-
tated. Whether this variability also attaches to the physio-
logically active iron compound obtained by the use of methyl
alcohol has not yet been determined.

Briefly stated, the results of the above experiments are as
follows: 1.197 grams of epinephrin bisulphate made from
the benzoyl compound were treated with ammonia until the
larger portion of the epinephrin was precipitated; this was
washed with cold water and the washings added to the origi-
nal filtrates. Both the flocculent free epinephrin and that
which still remained as a bisulphate in the filtrates were
converted into an iron compound. According to v. Fiirth.
only the filtrate and the washings from the free epinephrin
could yield an iron compound. Yet after all the manipula-
tions above described the following fractions of this iron
compound were obtained:

s Amer. Joiiru. of Plijsiol., vol. iii, 1S<)9-1!I00, No. 8, p. XVII.

March, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

From epincphriii,
Precipitate I.

0.1412 gram.

Fiom epinephriii,
Precipitate II.

0.3845 g-ram.

From the filtrates from
Precipitates I and 11.

0.3438 gram.

From the wasliings of those precipitates further amduiits
of the iron compoimd were obtained and in relatively the
same proportion in each case. These additional fractions,
together with what was recovered from filter papers, cylinders
and funnels, bronght the total amonnt of the iron componnd
obtained up to 0.9212 gram. A small quantity, amounting
to perliaps 0.02 gram was further precipitated from the wash-
ings of the last fraction and was not taken into consideration.

The object of the above experiment was to learn whether
this compound can be as easily made from floceulent, inactive
epinephrin as from its filtrates, but the fact which inci-
dentally appeared, that notwithstanding the inauy manipu-
lations involved, so large an amount as 0.9242 gram of an
iron compound was obtained from the above-mentioned quan-
tity of bisulphate, fairly warrants the statement that epi-
nephrin bisulpliate is quantitatively convertible into an iron
compound.

In tlie case of the iron compound from epinephrin. Pre-
cipitate IT, and from the filtrates from epinephrin. Precipi-
tates I and II, like conditions of precipitation were main-
tained both in respect to the amounts of the reagents em-
ployed and the reaction of the wash fluids, with the result
that the iron content of the two fractions was nearly the same.
This is shown in the following table:

Iron compound

from ciiinephrin,

Precipitate U.

0.110.5 gm. burned on an ash-
less tilter left 0.014 gm. Fe.^Oj =
8.87 per cent Fe.

0.174 gm. burned in a curi'ent
of oxygen, left 0.031 gm. Fe„Os =
8.44 Fe.

Iron compound from filtrates

Irom ciiinephrin.

Precipitates 1 and II.

0.09(1.5 gm. b\irned on an ash-
less filter left 0.0133 gm. Fe^O, =
8.8.5 per cent Fe.

0.1473 gm. burned in a current
of oxygen, leftO.OlSO gm. Fe.fl3=
8.06 per cent Fe.

The carbon and hydrogen content of the two fractions was
also in fairly close agreement, but the analyses are reserved
for consideration in a later paper in which I hope to give a
fuller comparison of this compound and that made by v. Fiirth
in the manner already described. A single analysis of a
specimen of tlie latter compound was made and it was found
to contain 12.8 per cent of iron.

This higher iron content unaccompanied by other data
affords no basis of comparison between the two substances;
for, as we have seen, a fraction of my iron comjtound which
contains 8.5 per cent of iron may by chemical manipulation
have its iron content raised to over 12 per cent.

In conclusion, then, it may be stated that an active salt
of epinephrin made by saponification from its benzoyl com-
pound is convcrtiljle into an iron compound, both in metliyl
alcohol and in aqueous solution.

When made from an aqueous solution this iron compound
is physiologically inactive, also less soluble in dilute acetic
acid than v. Fiirth's compound, but in respect to its chemical
reactions it is indistiuguishable from his coinjiound.

By benzoating the iron compound of v. Fiirlli, trial cxjieri-

ments have shown me, that the entire series of derivatives
formerly described by me may be obtained. From it I have
also made the acetyl compound and by decomposing it in the
autoclave I have obtained an active bisulphate indistinguish-
able in appearance and reactions from that formerly described
by me.

Our compounds also agree in yielding, on the addition of
moderately strong alkali, the volatile base of a coniinepiperi-
dine-like odor so often noted in my previous papers.

III. Other Effects of Treatment in the Autoclave.

V. Fiirth has also stated that the active ])rinciple of the
gland as contained in the fluids prepared from his lead or zinc
precipitates, yields no precipitates on the addition of certain
alkaloidal reagents, as picric, phosphotungstic or tannic acid,
iodine in potassium iodide or concentrated solution of zinc
chloride.

It is, however, easy to prove that here, too, as in the in-
stances relating to precipitability with ammonia and with
ferric chloride, we are dealing with characteristics which only
require appropriate treatment for their development. If the
iron compound prepared according to the directions of v.
Fiirth is converted into the acetyl derivative and this is
saponified in ihe autoclave, a solution is obtained from which
the epinephrin bisulphate formerly described by me can be
prepared without difficulty. Aqueous solutions of this salt
readily give precipitates with the above-named alkaloidal re-
agents, while solutions which are derived 'from the material
from which v. Fiirth's iron compound is prepared, that is to
say, from material which has not been exposed to hydrolysis,
fail to give jjrecipitates with these reagents.

A further instance of this behavior is ftirnished by the
compound already alluded to as having been sent to me by
the chemist of one of our manufacturing firms. Before treat-
ment in the autoclave with dilute sulphuric acid this sub-
stance also yields no precipitate with such alkaloidal reagents
as picric acid, phosphotungstic acid, iodine chloride or iodine
in potassium chloride, but after such treatment a prompt
precipitation occurs on the addition of these reagents.

IV. Skatol: a Decomposition Product of Epinephrin.

I have stated in previous papers that on fusing the chro-
mogen of the gland with powdered potassium hydrate and
then diluting with water the penetrating odor of skatol arises
from the solution. "When this solution of the fusion products
was shaken with ether and the ether allowed to evaporate,
little globules remained, having an intensely fsecal odor and
giving the characteristic reactions of skatol with sufllcicnt
definiteness to warrant the belief 'that this substance is a
decomposition product of the active principle under the
conditions specified.

V. Fiirth has failed to substantiate my statements in this
particular, but the tests which I have made with the acetyl
compound prepared directly from his own iron compound,
as also with a specimen of epinephrin bisulphate prepared

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 120.

from this acetyl derivative have still further convinced me
that my statements were correct. In order to get olfactory
evidence of the presence of skatol, it is only necessary to
smelt about 0.1 gram of either of these compounds in a
cautious manner with an appropriate amount of powdered
potassium hydrate, the two reagents being spread out on the
bottom of an Erlenmeyer flask, then to dilute with water,
shake with ether, and evaporate the ether out of a Urechsul
wash bottle with the help of a suction pump. The water
contained in the ether is left behind as ice and the low tem-
perature produced is an eifectual bar to the complete escape
of the skatol. On opening the wash bottle after the removal
of the ether one obtains sufficient proof that skatol is present
from its characteristic odor.

V. Analytical Considerations.

It would now be in order to give analytical data to illus-
trate the changes that occur in the autoclave and to show
what relation obtains in respect to elementary composition
between the autoclave product and its less manipulated, phys-
iologically more active counterparts. But an accident that
haj)])encd to me in my laboratory in the early days of Decem-
ber and which for nearly three months kept me from my
laboratory has made more than an introductory discussion
of this point impossible.

It would appear that the simplest method of arri\ing at a
conclusion in regard to the extent of the analytical differences
existing between epinephrin as made by the autoclave method
and that made by avoiding this treatment, would be to analyze
the acetyl derivative when made from v. Fiirtlfs iron com-
pound. The direct conversion of this iron compound into
its acetyl derivative contends with the difficulty of purifying
and washing the former substance in consequence of its amor-
phous character, and is also open to the suspicion that
secondary changes, such as oxidation, may occur in the pro-
cess of acetylizing. I have nevertheless converted^ this iron
compound into its acetyl derivative, without first removing
the iron. Preliminary analyses have shown that its nitrogen
content varies from 4.18 to 4.88 per cent. My empirical
formula, for triacetyl epinephrin as made by the autoclave
method, calls for 3.31 per cent N. In the above instances
the nitrogen content was determined by the method of Kjel-
dahl, and the observed deviation from the theoretical require-
ments are too large to bring the acetyl compound now under
consideration into a simple relation with that formerly de-
scribed by me.

It may be remarked in passing that the observed results
vary still more widely from those found by v. Furth, who
gives 5.71 per cent as the average nitrogen content of his
acetyl compound, while the theoretical requirement is either

5.81 or 5.86 per cent, according as the one or the other of his
assumptions that the active principle is tetrahydrodioxy-
pyridin or dihydrodioxypyridin is made the basis for the
empirical formula.

At tlic present moment it is impossible to express, in
analytical terms, the differences that exist between the epi-
nephrin of my former papers and the somewhat less altered,
native principle. Their cpialitative differences and resem-
blances have been pointed out in this paper. AVhile it is
perhaps unwise to anticipate the results of future researches,
I would suggest that one or more of the following chemical
changes may possibly account for the differences that have
been noted: 1. The saponification of the benzoyl derivative
may not be a complete one; one benzoyl group may have been
retained, in which case my epinephrin would represent the
monobenzoyl derivative of the native principle. 3. Inasmuch
as treatment in the autoclave of every form of the active
principle, no matter how prepared, leads to the appearance of
new properties, it is in order to ask whether the entrance of
one or more molecules of water into the compound, or the
loss of an atom of nitrogen in the form of ammonia or a
combination of these two alterations, will not be foinid to lie
at the bottom of the whole difficulty. In case one or both of
these changes take place, they would of course also occur in
the case assumed under 1. 3. It is also possil)le that the
autoclave is responsililc for a doubling of the original mole-
cule after previous elimination of water and also of nitrogen
in the form of ammonia or of a simple anime.

These and other points will constitute the subject matter
of a future communication. The methods that have hitherto
been employed by me have served their purpose in giving us
unstable but characteristic derivatives of the native principle.
These have retained a high degree of physiological activity
and give all the known reactions of the native product, but
they show, in addition to these, certain new reactions, such
as precipitability by ammonia and by alkaloidal reagents.

In conclusion I would state that the autoclave is also re-
sponsible for a decrease in the physiological activity of the
compound. This is shown by the data recently obtained by
Prof. Reid Hunt" with a specimen of unaltered epinephrin
bisul])hate, which was prepared from v. FiirtlTs lead precipi-
tate, by removal of the lead and su1)sc(pient fractional pre-
cipitation. Other methods of isolation in which also the use
of the autoclave plays no part are now in progress in my
laboratory, and detailed statements as to the composition and
physiological activity of the resulting products will follow
later.

6 Amer. Jour, of Physiol., vol. v, No. 2, p. VII.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

Volume XII is in progress. The subscription price is $1.00 per year. The set of twelve volumes will be sold for $23.00.

JlARCir, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

THE JOHNS HOPKINS MEDICAL SCHOOL.

FACULTY.

Daniel C. Gilmax, LL.D., President.

Ira Remse.v, M. D., Ph.D., LL.D., Professor of Chemistry.

Wir.i.rAM H. Welch, M. D., LL.D., Professor of Patholofr.v.

William 0.<LEit, M. D., LL.D., F. U. S., Professor of Medicine.

Henuv M. IIiEii), M. D., LIj.D., Professor of Ps.vch'.itry.

How.\KD A. Kelly, M. D., Professor of Gynecology.

William K. Brooks, Ph.D., LL.D., Professor of ZoOIo^y.

William S. Halsted, M.D., Professor of Surgery.

John .1. Abel, M. D.. Professor of Pharmacology.

WiLLUM H. Howell, Ph.D., Jf. D., Professor of Physiology, and Deau of the

Medical Faculty.
Franklin P. >L\ll, M. D., Professor of Anatomy.
J, Wmitriik;e Willia^is, M. D., Professor of Obstetrics.
William I). ISooker, M.D., Clinical Professor of Pediatrics.
John N. Mackenzie, M. D., Clinical Professor of Larynj^-ology.
Samuel Theobalii, M.'D., Clinical Professor of O|ilithalinology and Otology.
Henry M. Thomas, M. D., Clinical Professor of Neurology.
J. Williams Lord, M.D., Clinical l^rofessorof Dermatology.
Thomas C. Gilchrist, M. R, M. K.C. S., Clinical Professor of Dermatology.
Henry J. Berkley, M. D., Clinical Professor of Psychiatry.
Willum S. Thayer, M. D., Associate Professor of Medicine.
John M. T. Finney, M. D., Associate Professor of Surgery.
Boss O. Harrison, Ph.D., Associate Professor of .\natomy.
WiLLi.VM W. KrssELi>, M. D.. Associate Professor of Gynecology.
Thomas S. Cullen, M. B., Associate Professor of Gynecology.
Heid Hunt, Ph.D., .M.D., Associate Professor of Pharmacology.
Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.
Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. BLOODfiooD, M. D., Associate in Surgery.

Charles R. Bardeex, M. D.. .\ssociate iu .\natoray.

Harvey W. Cushino, M. D., Associate ia Surgery.

George W. Dobbin, M. D., Associate in Obstetrics.

W.vLTER Jones, Ph.D., .Vssociate iu Phj'siological Chemistry and Toxicology.

NOK.MAN MacL. Harris, M. B., Associate in Bacteriology.

William G. MacCalhtm, M. D., Associate in Pathology.

Frank R. Smith, M. D., Instructor ia Medicine.

H. B.\RTON .Jacobs, >r. D.. Instructor in Medicine.

HuoH H. VOUNO. M. D., Instructor in Genito-Uriuary Diseases.

Thomas McCrae, M. B., Instructor in Medicine.

Henry McE. Knowkr, Ph.D.. Instructor in Anatomy.

Percy M. Dawson, M. D.. Instructor in Physiology.

Eugene L. Opie, M. D., Instructor in Pathology.

Mervin T. SiTDLER, PH.D., Instructor in Anatomy.

George Walker, M. D., Instructor in Surgery.

Stewart Paton, M. D., Assistant in Clinical Xeurology.

Harry T. Marshall, M. D., Assistant in Pathology.

CH.A.RLES P. Emerson, M. D., .\ssistant in Medicine.

Elizabeth Hurdon, M. D., Assistant in Gynecology.

Henry I>. Reik, M. D., .\ssistant in Ophthalmology and Otology.

L. P. Hambur(;ek, M. D.. .\ssistant in Medicine.

F. W. Lynch, M. D., .Assistant in Obstetrics.

John B. MacCallum, M. D., Assistjint in Anatomy.

Warren H. Lewis, M. D.. .Assistant in Anatomy.

Joseph Erlanger, M. D., .\ssistant in Physiology.

H. W. Buckler, M. O., .Vssistant in Obstetrics.

William S. Baer, M. D., Assistant in Ik-thopedic Surgery.

GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1S03. This School of Medicine Is an in-
tegral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hos-
pital. The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the
middle of June, with short recesses at Christmas .ind Easter. Men and womcu are admitted upon the same terms.

In the methods of instrnctiou especial emphasis is laid upon practical work iu the Laboratories and in the Dispensary and Wards of the Hospital.
While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable
preliminary education and upon thorough training In the medical sciences. The first two years of the course are devoted mainly to practical work, com-
bineil with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology. Physiological Chemistry,
Pharmacology and To.xicology, Pathology and Bacteriology. During the last two years the student is given abundant opportunity for the personal study
of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for
thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work In the Dispensary, and throughout
the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives:

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

2. Graduates of approved colleges or scientific schools who can furnish evidence: (a) That they have acquaintance with Latin and a good reading
knowledge of French and German; (b) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given
In these subjects in this university.

The phrase " a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and
three hours a week In the laboratory are required; in chemistry ond biology, four class-room exercises and five hours a week in the laboratory in each
subject.

3. Those who give evidence by examination that they possess the general education implied by a degree In arts or iu science from an approved
college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above Indicated.

Applicants for admission will receive blanks to be filled out relating to tlielr previous courses of study.

They are required to furnish certificates from officers of the college or scientific schools where they have studied, as to tie courses pursued In physics,
cliemistry and biology. If such certificates are satisfactory, no examination in these subjects will be recpiired from those who possess a degree in arts* or
science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school will be required (I) to pass, at the
beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then
to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University,
and (3) to furnish .satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare
Instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

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been fulfilled, (2) that courses equivalent in kind and amount to those given here, preceding that year of the course for admission to which application
is made, have been satisfactorily completed, and (3) must pass examinations at the beginning of the session in October in all the subjects that have been
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since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon
these courses has steadily Increased with each succeeding year and indicates gratifying appreciation of the special advantages here afforded. M'lth the
completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the
academic year than that hitherto selected. It Is. however, believed that the period now chosen for this purpose Is more convenient for the majority of
those desiring to take the courses than the former one. The special courses of Instruction for graduates In medicine are now given annually during the
months of May and June. During April there is a preliminary course in Normal Histology. These courses are Iu I'athology, Bacteriology, ciiuical Micro-
scopy. General iledicine. Surgery. Gynecology, Deriiiatologj', Diseases of Cluldren, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology
and Rhlnology, and Ophthalmology and Otology. The instruction is intendid to meet the requirements of practitioners of medicine, and Is almost wholly
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and operating-rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the
several instructors that they are prepared to profit by the opportunities hero offered. The nuiiibcr of students who can be accommodated in some of the
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During October a select number of physicians will be admitted to a special class for the study of the Important tropical diseases met with la this
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BULLETH^^^^^^

THE JOHNS HOPKINS

HAL

Vol. Xll.-Nos. 121-122-123.

BALTIMORE, APRIL-MAY-JUNE, 1901.

[Price, 50 Cents.

CONTE

On the Study of Anutomy. By Lewellts F. Bakker, M. B., . .

On tlic Occurrence of Tails in Man, with a Description of the Case
Reported bv Dr. Watson. By Ross Gr.\nvii.i.e Harhlson, Ph.D.,
M. D., . '. "

>AGE

flfi

Dcvelopinent of the Fist's Intestine. By Jons BurcE MacCallum,
M. D., . . . "

Bilateral Relations of the Cerebral Corte.x. By K. Limion Mellus,
M. D.,

A New Carbou-Dioxide Freezing- Microtome. By Cuari,e.s Rl'ssell
Bardeen, M. D.,

Notes on Cervical Ribs. By Clinton E. Brush, Jr.,

On the Preservation of Anatomical Material in America by Means of
Cold Storage. By Abkam T. Kerr, B. S., M. D.,

On the Development of the Nuclei Pontis during the Second and
Third Months of Embryonic Life. By Margaret Long, . .

The Architecture of the Gall Bladder. Bv Mervin T. Si'dler,
PlI. D., M. D., ."

Kemarkable Cases of Hereditary Anchyloses, or Absence of Various
Phalangeal Joints with Defects of the Little and Ring Fingers.
By George Walker, M. D.,

Note on the Basement Membranes of the Tubules of the Kidney.
By Franklin P. Mall,

103
1(18

113
114

117
133
131)

130
loo

A Comparative Study of the Development of the Generative Tract
in Termites. By H. McE. Knoweh, Ph.D

A Composite Study of the Axillary Artery in Man. By J. M. IIitzuot,

1H5
136

PAGE

On the Origin of tlie Lymphatics in the Liver. Bv Franklin P.

Mall, ' ." 140

Bern's Method of Reconstruction by Means of Wax Plates as Used
in the Anatomical Laboratory of the Johns Hopkins University.
By Charles Russell Bardeen, M. D., 148

Model of the Nucleus Dentatusof the Cerebellum and its Accessory

Nuclei. By Harry A. Fowler, ISl

Use of the Material of the DissectingRoom for Scientilic Purposes.

By Charles Russell Bardeen, M. I)., 1.55

On the Development of the Human Diaphragm. By Franklin P.

Mall, . '. 158

Observations on the Pectoralis Major Muscle in Man. By Wauren

Harmon Lewis, M D., 173

On the Blood-Vessels of the Human Lymphatic Gland. By W. J.

Calvert, M. D., U. S. A., . . .'. . . , .177

Normal Menstruation and Some of the Factors Modifying It. By

Clelia Duel MosHER, A. M., M. D., 178

Kctrojcction of Bile into the Pancreas, a Cause of Acute Hemor-
rhagic Pancreatitis. By W. S. Halsted, M. D., 170

The Etiology of Acute Hemorrhagic Pancreatitis. By Eugene L.

Opie, m". D., 182

The John W. Garrett International Fellowship, 188

Notes on New Books, ISO

Books Received, 101

ON THE STUDY OF ANATOMY.'

By Lewellts F. Barker, M. B., Tor.
Professor of Anatomy, University of Chicago.

With tlio advent of October, with its cool and bracing days
and restful nights, there is regularly a quickening of activities
in academic circles. The occupant of a [irofcssional chair, re-
invigorated by temporary sojourn in forest or field, at the
seaside or in the hills, resumes his teaching with renewed
enthusiasm, and engages again in that original investigation
which represents the most absorbing interest of his life. The

' An address delivered before the Faculty and students of Hush
Medical College, October .5, 1000.

student, too, perhaps, as yet less conscious of the actual need
of an occasional remittance from his labors, has nevertheless
liad his holiday, and returns to the college of his clioice ready
for another season of diligent application and eager to begin
once more the arduous tasks which the pursuit of knowledge
entails.

It has long been customary in colleges in which medicine
is taught to call a meeting of tlie faculty and students at the
beginning of the autumn session. Such a meeting permits
of the reunion of former teachers and students and the intro-

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-133.

diiction and welcoming of new teachers and new students.
It gives, further, opportunity for the making of certain
special remarks; and I have noticed that there is almost
universally a tendency on the part of the faculty to grant
the privilege of remark-making to some memher of it who
has lately been added to the staff. Being myself one of the
most recent additions to an already large staff-family, the
privilege has this year been gracefully allotted to me. How-
ever great a sacrifice on the part of my colleagues this may
represent, I can assure you that the new-comer on this occa-
sion, like the distinguished memher of the faculty who last
year addressed you, considers it a great favor to have the
opportunity of expressing the pleasure he has in coming
among you and being counted one of you, and to meet with
an occasion on which he can more or less generally indicate
the aims and scope of the science which he represents, and
so publicly justify the position which he holds. Fortunately.
in this latter respect the task is an easy one, for anatomy has
in medicine long ago won its place as a science essential as a
basis for all the subsequent medical studies, and moreover,
my predecessors in office have been men of such sterling
merit, power and inspiration, that the subject is here appre-
ciated and reverenced. Especially true is this of him who
has immediately preceded me as the occupant of the chair,
and who has left it in order to accept a chair in surgery;
while we commiserate anatomy on losing so able a represen-
tative, we must congratulate surgery on the enlistment in its
service of so well trained and enthusiastic an anatomist. He
has at this college developed, among other things, a course
in surgical anatomy — easily one of the best given in America
— and this part of the anatomical work, I am glad to assure
you, he has promised, for the present at least, to retain. You
join with me I know in wishing my colleague, Professor
Bcvan, a continuation of that success which he has already
attained in the field of his ultimate choice.

The year in which we live marks an important epoch in
the history of the college. Of a whole series of advances, I
wish to call attention especially to one. Beginning with this
autumn quarter, a closer relationship than has ever before
existed between Rush Medical College and the University of
Chicago has been established. Not entirely satisfied — for
what true lover long is? — with that "sisterly" relationship
which the term " affiliation " represents, the college has this
year appointed to two of its fundamental chairs — physiology
and anatomy — men who are already the occupants of chairs
in the same sciences at the university. That such closer
bond of union cannot fail to be of the greatest value, both for
Rush Medical College and for the University of Chicago. I
confidently believe. That it is only the forerunner of a still
deeper intimacy, many, I am sure, both in the university and
the college, fondly hope.

On thinking over anatomical subjects in the search for
material for this address, the ideas which came to me grouped
themselves in the main under two headings: (1) Wiat does
the science of anatomy include? and (2) How can the study
of anatomy best be prosecuted? Each of these headings cor-

responds to matter enough for a single occasion; I have, there-
fore, decided to spend the time at my disposal this evening in
a consideration of the former of the two questions, and to
reserve for another time and place what I have gathered in
answer to the latter.

Of the whole group of the natural sciences, there is perhaps
no other member, the jirovince of which is less well under-
stood by the general public than is the science of anatomy.
As ordinarily thought of by the layman, it is a science the
study of which necessarily precedes the practical work of
medicine and surgery; a science which is largely, if not
wholly, descriptive, and one which to be mastered requires
prolonged oeciipation, scalpel in hand and pipe in mouth,
with dead and partially decomposed human beings. Such
a view of the science, though perhaps not surprising when
we recall the methods by which anatomy — so-called — has
frequently in this and other countries been prosecuted, could,
I do not need to tell you, be scarcely more widely removed
from the truth. Anatomy is not simply a descriptive science;
the study of it as a preparation for practical medicine and
surgery represents only one side of its interest and usefulness;
the scalpel is now perhaps the coarsest instrument it employs;
its work is by no means confined to the human body alone,
much less to the dead human body, and when it does deal
with the latter, the material can be so well preserved that
even the fragrant Havana is said to be more offensive to some
sensitive souls than are the odors from the well kept prepara-
tion room.

Even medical men differ markedly in their conception of
what anatomy includes, their ideas being based largely upon
the kind of anatomy they theniselves were taught, and upon
the anatomical needs of the particular branch of medicine
which, after graduation, they have cultivated.

Nor is there uniformity of opinion among the pure anato-
mists themselves, as can be readily seen by a perusal of the
various addresses made by scientific anatomists in different
parts of the world during the last twenty years. A free ex-
pression of opinion upon the subject has, however, gone far
.to make the aims and scope of the science clearer, until at
present its principal representatives are more nearly in accord
with regard to them than ever before.

In what this accordance consists, I can, I believe, make
clearest to you by glancing briefly at the various steps through
which the science has passed from the period when the ear-
liest anatomical observations were recorded to the present
day.*

- In the preparation of tliis address I have made free use of a large
number of addresses made on similar occasions by other anatomists. I
have had no hesitation in borrowing liberally as will be immediately
apparent to those who are familiar with the bibliography. Especially
useful to me have been the addresses and papers of His, Hertwig, von
Kolliker, Macalister, Mall and Waldeyer. The following are some of
the sources consulted :

Baker, F.: The rational method of teaching anatomy. Med. Rec,
N. T., 1884, sxv, 431-43.5.

Bevan, A. D.: What ground should be covered in the anatomical
course in American medical colleges ? And what part of this ground

A I'UI L-M A Y-JUNE, 1 00 1 .

JOHNS HOPKINS HOSPITAL BULLETIN.

There can be no doubt that from the earliest times, curios-
ity concerning and interest in the make-up of the human
body has existed. The references to man's body and its
organization frequently to be met with in the pages of the old
Hindu Vedas and of the earliest writings of all the Oriental
nations make this evident. Nevertheless, the awe in which
men stood before the human cadaver, together with the
penalties threatened by religious leaders for its molestation
appear to have effectually prevented any systematic examina-
tions and the little knowledge possessed by the ancients, aside
from the conclusions drawn from animals killed for food or
for sacrifice, seems to have been drawn from the instances in
which, through the violence of war, the chase, or of the nat-
ural elements, the human body became dismembered or evis-
cerated.

The earliest dissections of the human body of which no
doubt exists are those which were undertaken at the Alexan-
drian School (B. C.) by Herophilus and Erasistratus, sup-
ported and protected by the intelligent Ptolemaic rulers.
The name of Herophilus is still familiar to every beginner of
anatomical studies in tlie* term Torcular Herophili. The
statement is made, though I hope it is not true, that these
daring anatomists went so far, with Ptolemy's sanction, as

should be covered in the first year? What in the second year? Proc.
Ass. Am. Anat., Wash,, l.S'.)4, vi, 47-40.

Brown, .1. J[.: Tlie science of human anatomy ; its history and devel-
opment. Edinb. M. J., 1SS4-5, x.xx, 58.5-596.

lirownina;, W. W.: Remarks on the teachins;; of practical anatomy.
Brooklyn M. ,]., 1894, viii, 329-341.

Budge, J.: Die Auftrabeu der anatoraischen Wisseuschaft. Deutsche
Rev., 1882.

Cleland, J.: Lecture on anatomy as a science and in relation to mctlical
study. Lancet, Lond., 1892, ii, 93S, 982.

Cooke, T.: The teaching of anatomy ; its aims and methods. Lancet,
Lond., 1893, ii, 1153, 13.^)0.

Cuuniugham, D. J.: Bologna; the part which it has played in the
history of anatomy; its octo-centenary celebration. Dublin. J. M. Sc,
1888, 3 s., .x.x.xvi, 4li5-484.

Debierre, C: L'Anatomic, son passc, son importance et son role dans
les sciences biologiques. Rev. Sclent., Par., 1883, 3 s., xv, 68-74.

Duval, M.: L'Auatomie guucrale et son histoire. Rev. Sclent., Par.,
1886, xxxvii, 65-107.

Dwight, T. : The scope and the teaching of human anatomy. Boston
M. and 8. J., 1890, cxxiii, 337-340; also, methods of teaching anatomy
at the Harvard .Medical School : especially corrosion preparations.
Boston M. and S. J., 1891, cxxiv, 47.5-477.

Flower, W. U.: An address delivered at the opening of the section of
anatomy. Tr. Interuat. M. Congr., Loud., 1881, i, 133-144.

Gegenbaur, C: Ontogenie und Anatomie iu ihrcn Wechselhezi'lch-
ungen betraehtet. Morphol. Jahrb., Leipz., 1899, xv, 1-9.

Ilertwig, O.: Der auatomische Unterricht, Jena, 1881.

llartwell, E. M.: The study of human anatomy, historically and legally
considered. Johns Hopkins Univ. Stud. biol. lab., Balto., 1881-2, ii,
65, lie,.'

His, W.: Ueber die Aufgabcn und Zielpunkte der wissenscliaftlichcn
Anatomie. 'Leipzig, 1873.

His, W.: L^eber die Bedeutung der Entwickelungsgeschichtc fiir die
Aufl'assung der organisehen Natur. Leipzig, 1870.

Humphry, G. M.: An address on the study of human anatomy. Brit.
M. J., Lond., 188T, i, 1030.

to dissect living criminals, from which Tertullian designated
Herophilus as laiiius (Fleischer).

This opportunity for the anatomical investigation of the
human body appears to have been unique, and it continued
only for a short time. Even Galen's studies, the results of
which were held for the following ten centuries at least to be
infallible, were limited to the bodies of animals; he recom-
mended, it may be remembered, the study of the bodies of
apes and swine — the animals which in his opinion were
nearest to human beings. After Galen, the natural horror
which the examination of the dead body excites, together with
the edicts of the church against dissection, prevented any
further progress of descriptive human anatomy for a very
long period. The church declared that Galen had been in-
fallible, and that therefore no further anatomical studies were
necessary. Fortunately for science, which knows but little
infallibility, certain of its votaries in liigh favor at Eome
gained permission, in the fourteenth century, to make dis-
sections of human bodies, and to use them for demonstration
before students. Mondini in Bologna again opened the path
for scientific anatomical inquiry and started in Italy a move-
ment which placed that country, as far as medicine is con-
cerned, in the lead. Students from distant lands were at-

Kollikcr, von A.: Die .Vufgiihen der anatomischen Institute, Wiirzburg,
1884.

Krause, W.: Die Methode in der Anatomie. Internal. Monatschr. f.
Anat. u. Histol., Berl., 1884, i.

Keiller, W.: The teaching of anatomy. N. York M. J., 1894, ix, 289,
513, .545.

Keen, W. W.: A sketch of the early history of practical anatomy.
Philadelphia, 1870.

Macalister, A.: Introducing lecture on the province of anatomy.
Brit. M. J., Lond., 1S83, ii, 808-811.

Mall, F. P.: The anatomical course and laboratory in the Johns Hop-
kins Medical School. Johns Hopkins Hospital Bulletin, 1896.

Meyer, von H.: Stellungund Aufgabeder Anatomie in der Gcgenwart.
Biol. Centralbl., 1883.

Marks, G. IT.: The study of anatomy; its position in medical educa-
tion in England and in America. Boston M. and S. J., 1885, cxiii, 104-
107.

Morris, 11.: An address on the study of anatomy. Brit. M. J., Lond.,
1895, ii, 1337.

Pepper, W.: Introductory remarks at the ojiening of the Wistar
Institute of anatomy and biology. Univ. iM. Mag., Phfla., 1893-4, vi,
569-572.

Robinson, B.: A plea lor the more thorough study of visceral anatomy.
(Jalllard's M. J., N. Y., 1894, ix, 289-296.

Schiell'erdecker, P.: Der auatomische Unterricht. Deutsche Med.
Wehnschr., Berl., 1882, viii, 46.5-467.

Shiels, G. F-: A plea for the proper teaching of anatomy. J. .Am.
Med. Assoc, Chicago, 1894, xxiiii, 110-112.

Testut : Qu'est-ce que I'homme pour un anatomiste ? Rev. Scicnt.,
Par., 1887, 3 s., xiii, 6.5-77.

Turner, W.: Address at the opening of the anatomical department in
the new buildings of the University of Edinburgh. Lancet, London,
1880, ii, 724, 759.

Virchow, R.: Morgagni und der auatomische Gedanke. Bcrl. Kl.
Wehnschr., 1894, xx.xi, 34.5-350.

Walton, G. L.: The study of anatomy in the Leipzig University.
Boston M. and S. J., 1883, cvi, 389.

Waldeyer, W.: Wiesoll man Anatomie lehren und lerneu. Berlin, 1884.

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

tracted, as tliey always have been and always will be, to tlie
point where progress was making the greatest headway.

The great Vesalivas, often known as the father of anatomy,
was among these wandering scientists. Born in Belgium and
edneated in France, he prosecuted his anatomical studies in
Italy, especially when professor at Padua, to such a degree
that he merits a place among the world's greatest reformers.
This energetic, truth-seeking, idol-breaking, authority-deny-
ing man, dared to look at things as he saw them rather than
as Galen had said that they should be, and thus made dis-
coveries of the first importance in anatomy; by his artistio
powers he rendered many of tliem imperishable; best of all,
lie broke forever the tyranny of tradition in anatomical
knowledge, and threw wide open the gate by which men
must always enter in the pursuit of anatomical truth.
Vesalius was a contemporary of Liither; the year of his death
is that of the birth of Galileo and of Shakespeare.

It was the spirit which animated Vesalius which later led
William Harvey, the founder of physiology, to the discovery
of the circulation of the blood, and Giovanni Battista Mor-
gagni, the founder of pathology, to that mode of conception
which Virchow has designated " the anatomical idea in
medicine." It is the spirit which is embodied in every scien-
tific worker of to-day who accepts the records of past inves-
tigation only as a guide — a guide which must be fallible
since it is human — and which, therefore, must be repeatedly
controlled; a guide which needs constant revision on account
of the ever-increasing extension of the domain of sense, and
ime, which, if not added to significantly by the scientist in
his lifetime, will stand as an everlasting witness to his in-
efficiency, a perpetual testimony to his lack of consequence.

Like all the natural sciences, anatomy in its earlier stages
consists, of necessity, in the amassing in an empirical way
of a store of naked facts. In other words, the subject is
purely descriptive until a suflBcient number of facts have been
collected to make their arrangement and classification a task
worth while. Adequate descriptions are based upon intelli-
gent ohscrvatioti, which in turn is dependent upon the skillful
use of the organs of sense, including the means which modern
technique is ever inventing to extend them. The body is
e.xamined externally and internally in its various parts; it is
looked at; it is felt. The size, shape, color, weight, consist-
ence and reciprocal relations of the parts are noted; the re-
sults are recorded, the attempt being made to establish thd
material content of the science with all possible certainty,
sharpness and clearness. The parts have first to be distin-
guished and named; then accurately described, their physical
characters being established in language. The description of
a natural object that shall call up in the mind of the reader
a precise image of the object and that shall serve as a reliable
guide to a succeeding observer, does not fall within the prov-
ince of every man's capacity; happy indeed is the anatomist
who possesses the power, for as has more than once been
pointed out, an exact and clear description of the known is
often of as great value as the so-called " discovery " in the
region of the unknown.

The satisfactory naming of the various parts alone is a task
of far greater difficulty than at first appears. An object must
be studied for a long time, in many coimtries, and by men
who know the relations of anatomy to every subject with
which that science is allied, before a name for a part which
shall be in accord with all the requirements can be decided
upon. Almost every part has at various times received a
series of names; periodical revisions of nomenclature by repre-
sentative committees are accordingly desirable in order to
arrive at uniformity among anatomists and to relieve the
science of an immense niimber of names, since at best it must
be grievously burdened.

Ever since the time of Vesalius there has been an unbroken
series of anatomical observers who have devoted their powei's
to the attaining of skill in dissection and anatomical descrip-
tion. With energy and endurance and often at great personal
sacrifice, this band of anatomists has developed this side of
our science until it has reached the degree of precision which
characterizes it to-day; a state indeed which many believe to
be practically complete and incapable of further progress.
Of the difficulties overcome by Americans in helping with this
work since Mr. Giles Firman made the " first anatomy of the
country," a good idea can be gained from the admirable his-
torical review which we owe to E. M. Hartwell. While it is
obvious that there must be a temporal limit to the discoveriea
which the naked eye is to make in anatomical fields, one has
nevertheless only to refer to the current journals to see that
the limit has not yet been reached. But the limits of pro-
gress in anatomical description will by no means be syn-
chronous with those of macroscopic discovery of the objects
themselves, indeed, considering the complexity of man's
architecture and the different and ever-varying view-points
whence descriptions are being written, it is scarcely conceiv-
able that man will ever attain to descriptions which will be
satisfactorily final. To the surgeon, to the artist, to the
physiologist, to the scientific anatomist, the details of parts
are of utterly different significance; the varying scale of
anatomical values requires in each case a special description;
an objective characterization of all details, merely as such,
would make anatomical descriptions so ponderous and chaotic
as to render them totally useless to any one. Nor can ana-
tomical illustrations, in colors and otherwise, which are per-
haps even more valuable than anatomical descriptions, ever
be completely objective. The exact plates of anatomical
objects which approach of late years ever nearer to that degree
of accuracy which will permit of the taking from them of
mathematical measurements, never attain actually to perfec-
tion; there must always be an element of subjectivity in them
which may be inconsonant with the needs of some other
observer at some other time.

Again, the greater or less degree of variability to which all
parts of the animal body are subject, makes it difficult for
anatomists to agree as to what shall be called normal, and
thus the same object has frequently to be described in several
different ways and multiply and exactly represented in pic-
tures. There thus remains and ever will remain a task for

Apeil-Mat-June, 1901. J

JOHNS HOPKINS HOSPITAL BULLETIN.

the anatomist in the domain of anatomical description and of
anatomical illnstration.

If it be true that in the fields just referred to there is still
much work to be done, the statement is all the more justified
with regard to the taking of measurements and weights of
the body and its jjarts. The shape of the natural objects is
nearly always such that the localization of fixed points whence
measurements can be taken is rendered very difficult — so
difficult that frequently the comparison of the measurements
of one observer of an object with those of another observer
of the same are useless. Again, owing to. the variability of
the bodily dimensions in the two sexes, in different races, at
the various ages of life, according to individuality or under
different physiological conditions, nnless a whole series of
data accompany a given measiu'ement, the result may be of
no value to a succeeding observer. In modern anthropology,
however, definite criteria are always attended to and tlie
measuring metliod is proving to be of the highest service in
the elucidation of the questions that science has to solve.

The difficulties of anatomical measurement in large part
obtain also when the weighing of anatomical objects is imder-
taken. Notable results have already been obtained, however,
not the least of those in connection with the central nervous
system being gained through the comparatively recent work
of my colleague. Dr. Donaldson, in the university. The
application of the method to the determination of the normal
by Thoma may also be referred to as the beginning of a
long series of investigations which, in the end can scarcely
fail to be of the greatest importance. As liis, who has dis-
cussed this and the foregoing subjects in an admirable man-
ner, points out, it is difficult to imagine how the study of
variations in constitution is to be approached unless this and
similar methods are employed. As he says, it must be of
decisive influence for the physiological capability of an indi-
vidual, whether in his organization the musculature predomi-
nates over his nervous system, his epithelial tissues or his
glandular organs, whether his heart is relatively large or
small, whether accordingly it can increase the average blood
pressure in the arteries to a great or to a slight degree,
whether the man has a large or a small liver or whether ho
has a long or short alimentary canal. The study of anatomy
with the unaided sense-organs is, as we have seen, one of no
small magnitude, and one not yet completed. What then is
to be said of that descriptive anatomy which invades the
territory in whicli the eye only with the aid of the micro-
scope can penetrate? The field of the microscopic anatomist
is at least a thousand times wider than that of the macro-
scopic worker, and in that field, what has been said above
concerning description, pictorial representation and anatom-
ical measurement, equally holds good. It will yet be long ore
the collection of microscopic data will have been completed.
New methods open up new problems, and at present progress,
descriptive and microscopic anatomy may probably occupy
workers for centuries to come. Even with the methods and
microscopes now at our disposal, we have entered a museum.
the largest part of whicli has yet to be accurately catalogued,

and who can say what new doors the methods and the micro-
scopes of the century just before us are about to open vip?
The science of histography is almost as undeveloped as was
geography before the voyage of Columbus. Between the
histographic world of to-day and the arcbitectural world of
stereochemistry who will dare to prophesy what rich terri-
tories may exist?

The mere observation and registration of naked facts does
not, however, satisfy for long the cravings of the investigating
human intelligence. Indeed, there is something of a blunting
character about the process if long continued without the
synchronous operation of other faculties of the intellect.
Man is a classifying and generalizing animal; there lies deep
in his nature a desire to arrange the facts he observes in an
orderly manner, with the object of understanding them. It
is in the attempt to satisfy this human tendency that anatomy,
instead of remaining a purely descriptive science, becomes
elevated to a plane on a level with the other inductive
sciences.

Evidences of attempts at anatomical classification are found
among the earliest anatomists. The close resemblance of
certain parts of one another soon gave rise to the idea of
organic systems; such as the muscular system and the nervous
system. The keen observations of Aristotle on the paries
similares and the partes dissimilares may be recalled, as well
as those of Fallopius outlined in his Tradatus quinque de
partibus similaribus. It was left to the organizing brain oi
the yoimg Frenchman, F. Xavier Bichat, to get a grasp for
the first time of the relations of elementary tissjies to tho
general architecture of the body. Although, through over-
work and impecuniositj', his penetrating eyes were forever
closed at the early age of about 30 years, Bichat left behind
him three treatises — his " Traite des Membranes," liis " Ee-
cherches physiologiques sur la vie et la mort," and his
" Anatomic generale " — a legacy so immense that we cannot
help lamenting with wondering regret the too early arrest
of his labors. He recognized the fact that whereas in chem-
istry the more complex bodies are composed of simple ele-
ments, so in the architecture of man's body, simple tissues
are variously combined to form the complex mixture of tissues
which are ordinarily known as organs. He distinguished
some 21 systems or tissues — the cellular, the osseous, the
fibrous, the cartilaginous, the nervous, the muscular, the
medullary, etc., basing his classification on the manner in
which each tissue behaves in the presence of various reagents,
the physical and vital properties of each and, finally, the
character of each when met with under diseased conditions.
In other words, Bichat was the founder of the modern science
of histology, or, as it is sometimes designated, " General
Anatomy." '

Before following the progress of anatomy further along
this line, a word must be said concerning what must be re-
garded perhaps as the first direction taken by the investigat-

'Cf. Duval, M.: L'Aiiatomie generale et son liisloiro. Rev. Scient.
Paris, 1886, xxxvii, 05, 107.

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-133.

ing mind toward the understanding of organic forms — namely,
the pli3'siological (in its first stages, the purely teleological).
As has long since been pointed out, the language of anat-
omy is sufficient evidence of the long existence of the teleo-
logical conception in this science. For thousands of years
the individual parts of the body have been known as " organs,"
and the processes going on in them as " functions." Just as
function was unthinkable without a corresponding organ, so
an organ without function was inconceivable, and thus wher-
ever, in the series of well-understood parts of the body, one
remains over whose purposeful participation in the processes
of life is not understood, towards this is directed over and over
again the mental acumen of the investigator to assign to the
reluctant organ a definite significance.* It is not my purpose
here to enter into a discussion of teleology. The world has
been widely enough explored to utterly dispose of that gross
anthropomorphic form of teleology which pointed to a
humanly scheming architect of the universe, and whether or
not we accept some more correct form of teleology is, at
present, matter for individual opinion. This much is certain,
that while no teleological view of nature actually explains the
organization of a human body, the teleological conception
has been particularly heuristic in its effects in the investiga-
tion of the relation between the physical processes in, and
the physical characters of, the various parts of the body.
Ever since Galen, though animated by a false teleology, wrote
his De usu partium, in which the size, position, number, con-
sistence and structure of the various parts are treated as
facts which can be understood only through the investigation
of the purposes which they subserve, this mode of considera-
tion has been among the most influential. Even to-day a
large part of the profitable research undertaken by anato-
mists, physiologists and pathologists, has for its aim tho
elucidation of the relation of structure to function, especially
in microscopic domains. The work done in Ludwig's labora-
tory was largely of this nature, and as recently as 1883, H. v.
Meyer" has asserted that the only possible way of under-
standing the organs is to proceed to the study of them froii)
the physiological view-point. But if this were true, then all
scientific anatomy would be physiology, a statement which
narrow-minded physiologists might applaud, but whirli
broader men know to be untrue. Physiology is one of tho
daughters of anatomy, and is not likely so soon to forget the
fifth commandment. Johannes Miiller was the last great
scientist who covered both fields of anatomy and physiology;
since his time investigators have cultivated one of (lie two at
the expense of the other, a division of labor which we must
recognize on the whole as beneficial, though that it is accom-
panied by certain drawbacks must also be confessed. Especi-
ally difficult is it to sharply separate the study of strueturo
from that of function in the science of cytology, founded by
Schleiden and Schwann, pupils of Johannes Miiller in the

*Cf. His, W.: Ueber die Bedeutuna; tier Entwickehingseeschiclite fiir
die Auffassiing dcr Organiscbe. Natiir. Leipzig, 1870.

>■ V. Meyer, IT.: Stellnno' und Aiifgabe der Anatomie iu der Gegen-
wart. Biol. Ceutralbl., 188.3, No. 12.

fourth decade of this century. The development of the cell-
doctrine, modified as it was somewhat later by the introduc-
tion of the protoplasm-theory by Max Scliultze, marks a
most important epoch in the history of both anatomy and
physiology. Its value for the more practical side of medicine
is sufficiently in evidence when one of its direct outgrowths,
the cellular pathology of Eudolph Virchow, is recalled. The
appalling elaboration of technical methods during the last
few years has led to the accumulation of cytographic data
which remove all the comfort we once had in looking upon
the cells as elementary structures. Though cytophysiology
is as yet far behind cytography in its state of development,
there no longer remains any doubt that in approaching the
cell we stand before an organism of enormous complexity of
constitution, endowed with functional activities which must
for long remain to us unfatliomable. Any one who has
worked much with protoplasm and nucleus, with archiplasm
and centrosome, with cell-fibrils and cell-granules under
various physiological conditions, cannot fail to appreciate the
fact that here only the threshold of inquiry has been crossed —
the exploration of the real nature of the cell only just begun.
Indeed the evidence is fast accumulating in favor of the
opinion that many of these morphonuclcar cell constitu-
ents represent precipitates due to the action of reagents,
and the laws governing their regular appearance under defi-
nite conditions are being investigated. It is exactly in these
studies that structural and functional investigation still do
well to go hand in hand, a fact which a survey of the cyto-
liigical handbooks, now becoming so nunioroiis, will show, is
meeting with general recognition. I believe it was Du Bois
Reymoud who ventured the statement that " an ocean steamer
with all its machinery and intricacies of construction is far
less complicated in its composition than a cell." Would that
the cell were no more complicated than the ocean steamer in
construction! — the modern investigator would then soon be
ready witli the solution of its problems. Alas! the difficulties
are not confined to the study of these organisms as indi-
viduals; already we have entered upon the investigation of
their social relations, and cell-altruism and cell-egoism, cell-
states and revolutionary cells are discussed as actively among
cytologists as are the similar social questions concerning
organic individuals of another order by the people at large.
Further, in cytophysics and cytochemistry, research is at
present most active — these subjects representing one of the
most interesting subdivisions of recent physiology. Should
the gulf between the present microscopic picture of the cell
and its chemical structure ever be bridged, stereochemistry
would enter into the domain of anatomy. So much in gen-
eral, with regard to the physiological view-point in anatomy.
Closely allied to the foregoing, and in reality an offshoot
from it, is the mode of consideration of the surgical and
topographical anatomist. In this branch, the- individual re-
gions and cavities of the body are dealt with Avitb regard to
the reciprocal position of the various organs and systems.
Surgical anatomy studies these relations only in so far as they
are of importance in operative procedures; topographical an-

Aphil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

atomy, a wider subject, studies tlie relations mentioned and
independently of their significance to the surgeon. The
various regions of the body are studied sometimes in layers,
sometimes with regard to serial clues to a particular structure.
Sections of frozen cadavers have here proved to be of great
value for the study of relations and for helping the student
to make mental reconstructions of the parts analyzed by dis-
section. Surgical and topographical anatomy are thus seen
to be subjects of very high practical importance — the former
especially for the surgeon, the latter also for the worker in
internal medicine. It is this kind of anatomy Which has been
brought to so high a state of cultivation in Great Britain,
and especially in London, where most of the anatomy has
been taught by men in surgical practice. Valuable as such
instruction is for furgery and medicine, it should not be for-
gotten that it is applied anatomy rather than anatomy proper,
and no less a scientist than Macalister has deplored the
lack of advances in anatomy in England, attributing it largely
to the one-sided mode of instruction in vogue, and to the
examinations, to the passing of which the teaching is in large
part directed. Surely certain morphological considerations
are as important for the student of anatom.y as the learning
by heart of the various relations of an artery, especially if the
student is not to become a surgeon; it would be melancholy
indeed if there were not at least some members of the ana-
tomical classes who regard the study of the architecture of
the brain and spinal cord as interesting and as important as
that of the perineum.

But anatomy as a science would never have attained to the
dignified position it now holds had the minds engaged with
it remained satisfied, after observing and registering its ma-
terial content, with attempting the explanation of the human
body from the physiological view-point or by exliausting the
possibilities of its relation to the surgeon's knife.

As in the other natural sciences, the causality-need of the
intelligence has forced the anatomist to undertake the investi-
gation of the origin of the organic forms which he studies,
and of the relations of these forms to other similar and dis-
similar organic forms accessible to examination. In other
words, the comparative and the genetic methods of study
have been resorted to. Comparative anatomy and embry-
ology together constitute morphology, at least in the senso
in which the term is ordinarily used, and in morphology we
recognize the part of anatomy which makes it truly worthy
of being designated a science.

In the application of the comparative method, not only are
the different parts of the human body compared with one an-
other— the arms with the legs, the brain with the spinal cord,
the skull with the vertebral column, the various segments and
segmental partitions with one another — but man, recognized
as a member of a long series of animals, is compared with each
of them in turn, and they with one another, with the object
of establishing groups of type forms and of learning the plan
of architecture, not only of the single creature, but also of
the whole series. At first, anatomists studied the forma
which to them seemed to resemble man most closely, but the

gradual transition from one form to another was so striking
that animal after animal was studied until finally the whole
world of organisms has been submitted to the examination
of the comparative investigator. Oken and Goethe, Cuvier,
Meckel, Geofl'roy, St. Hilaire, Lamarck, Wallace, Darwin,
Haeckel, Huxley, Gegenbaur and Leidy are names which have
become very familiar to us in this field. The world of living
creatures is a unitary system, of which man is an inseparable
portion. First, when the whole system has been worked
through do the form and significance of many of man's parts
become intelligible. The animal series can be thought of as
a tree with the simplest forms at the root, the trunk branch-
ing at its origin, each branch in turn subdividing into limbs
and twigs until the highest degree of differentiation is
reached. It is this recognition of the lawful relation of
organisms to one another which the study of comparative
anatomy has afforded us. Such a recognition, now general,
was little less than startling to those who first arrived at it.
That it pointed to some more general law was obvious. As
Goethe himself, no mean participator in comparative studies,
beautifully expressed it:

" Alle Gestalten sind ahnlich und Keine gleicbet der anderm,
Und so deutet das chor auf ein gelieimes Gesetz."

Has this secret law been discovered? Many believe so and
look upon Darwin's doctrine of descent as a generalization
worthy, on account of its scientific value, of being placed side
by side with Newton's theory of gravitation. Whether the
evolutionary doctrine be unequivocally accepted or not, cer-
tain it is that the relationship of forms which comparative
anatomy reveals, finds in this genealogical conception of Dar-
win a more satisfactory explanation than any other hitherto
offered.

Closely allied to the phylogenetie mode of consideration is
that \\hich we designate as the embryological ontogenetic or
developmental. In the human species, as in every other, the
life of the individual member is of short duration; each
human organism has a beginning, a period of growth and
development, followed, even in the life of maximum length.
in the course -of a few decades, by decline and death. Gener-
ation follows generation as wave follows wave on the surface
of a ruffied sea. In the transference of life from one genera-
tion to another the material substratum sinks to a minimal
amount — the new human being begins as a fertilized egg-cell
1-120 of an inch in diameter, weighing only a minute frac-
tion of a gramme. From this simplest of beginnings it gradu-
ally passes through a long series of developmental stages, the
character of these stages varying somewhat under environ-
mental influences, each .stage being the nnecessary consequent
of a preceding stage, and at the same time the necessary ante-
cedent of the stage which follows it until finally the organism
attains to the fullness of differentiation of which, under the
circumstances of its environment, it is capable.

In this long series of developmental stages which every
mammal passes through, the earliest are very, very simple and
correspond in form closely with the lower forms in the animal
kingdom. But as cell-division in the embryo proceeds, the

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

shaping of tlie organism becomes more complex, resembling
higher and higher forms of animal life, nntil finally that of
mammals is assumed. Even at this period the nnskilled ob-
server might easily be confused if he were required at a glance
to distinguish a human embryo from those of several other
mammals at a similar period of development. Ultimately,
the differential characters of the species become clearly
marked, and even the tyro can easily recognize them Tiio
more skilled the observer, however, the earlier in the develop-
ment will the species-criteria be decisive.

Comparative embryology becomes all the more astonishing
a study when we realize that the embryological history of
every higher animal is, for a long period at least, almost
identical with that of a whole series of allied forms. No
wonder, then, this state of things being acknowledged, that
the embryologists, like the comparative anatomists, have pic-
tured the genetic relations of the different animal forms also
as a tree, a tree which on close examination is found to accord
very closely with the tree of relationship constructed by the
comparative anatomists.

Comparative anatomy and embryology are, therefore,
closely interwoven subjects, and each may, in a way, be looked
upon as a control for the other, though each has its special
problems, and each sets about the solution of these in a
manner peculiar to itself. Take, for example, the attempts
at an explanation of the series of forms through which the
individual passes in its development. Many comparative an-
atomists, accepting Darwin's doctrine of the origin of species
through a struggle for existence among generations influenced
by heredity and variation, would explain the development of
tlie individual member of a species as a temporarily com-
pressed recapitulation of the developmental course of the
species as a whole. While this doctrine that " ontogeny re-
peats phylogeny" has been maintained by eminent scientists
there are others who are unwilling to accept what cannot bo
proved; and some of the embryologists especially feel it their
province to attempt to explain from embryological studies
alone, and without reference to phylogenetic history, the
origin of the various form-stages through which the indi-
vidual passes. Already great strides have been made in the
direction mentioned, especially through the investigation of
the laws of growth; and the field of developmental mechanics,
though so lately entered upon, has proven to be one of the
most fruitful of those thus far tilled. One of the foremost
investigators along these lines goes so far as to assert that
the growth of every organic germ must, as a process strictly
regulated according to time and space, possess a mathematical
expression in which the velocity of growth of each point is
determined in its dependence on the time and the position.
Whether such formulaa will ever be set up and the kingdom
of organic forms thus subordinated to the domination of
simple numbers, seems doubtful, but in any case the con-
ception is an interesting one. We need not, however, look
into the nebulous distance for the advantages to accrue from
developmental study. Fear at hand are thousands of facts
of the greatest importance for anatomy as a whole and for

the practical branches of medicine and suvgei'y to be gained
only through this method of study. Scarcely a part of the
body but what is now better understood than was otherwise
possible. I need only mention the remarkably complicated
morphology of the brain and the sense organs, the distribu-
tion of the intestines, the grouping of the various voluntary
muscles, the puzzling course followed by certain of the
nerves and of the reproductive organs in the two sexes, to
call to mind some of the features which embryology has gone
far to illuminate.

I dare not pass by unnoticed here two phases of investiga-
tion which naturally follow upon the others, but which have
only very recently begun to be extensively cultivated, viz.:
those of histogenesis and of comparative histology. Histo-
genesis stands in the same relation to comparative histology
as does embryology to comparative anatomy. Indeed, it is
simply jDUshing the microscope into embryology and com-
parative anatomy, and is, in a way, comparable to the advance
from gross descriptive anatomy to microscopic anatomy. By
histogenesis we mean the study of the development of the
individual tissues, including that of the individual cells (cyto-
genesis). By comparative histology and cytology we refer to
the comparative microscopic study of the various tissues and
cells through a series of animals. The light throuTi upon
many of the unsolved problems of structure by these methods
is unexpectedly brilliant, and the future has much to hope
from it; MacCallum, too, has shown how important these
methods can be in helping to explain certain pathological
phenomena met with in heart-muscle, and there can be little
doubt that we are on the brink of the discovery of a series
of relations between histogenetic ccmditions and j)athological
processes.

Lastly, as a crowning piece to the whole system of ana-
tomical study, experimental morphology must be recognized.
As but a child among the kindred sciences, it is of robust
constitution, being the offspring of vigorous parents, and, in
this country especially, in an environment most suitable for
its healthy growth. The anatomist is no longer confined to
the study of adult forms, or of forms in their natural mode
of development; he can now, to a certain extent, artificially
control form-production by resorting to the experimental
method. The experiments which have been made upon
heteromorphism, upon the artificial production of malforma-
tions, and upon the grafting of embryos, are full of interest,
so much so as to disturb the equanimity of the soberest of
scientists. During the last year or two we have been — I was
going to say — shocked by the bringing of the proof by my
colleague. Professor Loeb, that the eggs of several forms not
naturally parthenogenetic can be fertilized — or at any rate,
brought to development in the absence of spermatozoa, solely
through the action of (?) physico-chemical influences. With
miracles such as these already performed, we can but stand in
awe of the work of the future.

Most sketchily and imperfectly 1 have tried to give yon an
idea of what the study of anatomy includes, viz.: descriptive
or systematic anatomy (gross and microscopic), physiological

April-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

anatomy, surgical and topographical anatomy, histology or
general anatomy, ineUiding histography and cytology, com-
parative anatomy, embryology, comparative histology and
embryology, histogenesis and lastly experimental morphology.
Assuredly the subject is wide. It is, I am sorry to say, too
wide to be mastered in all its details even when a whole life-
time is devoted exclusively to it. The scientific anatomi;;!,
after familiarizing himself with the main facts and principles
of its various subdivisions, does best, in agreement with the
great law of division of labor, to direct his efforts towards
the acquisition and promulgation of knowledge in some one
portion of it.

And now for a word of welcome to the class just entering
upon the study of medicine. You have taken, gentlemen,
the first direct step which is to lead you into one of the noblest
professions in the world — into a profession in which your
lives are to be consecrated to the service of suffering men
and women. You have to learn the laws which govern hcallli
and those which underlie disease. Yon, like your prede-
cessors, will find that a large proportion of your time and
.energy in life will be directed toward the prevention" of the
occurrence of disease, rather than to the cure of it, for medi-
cal men have the proud distinction of being perhaps tlie only
workmen " who make it their first duty to stop the sources
of supply from which they derive their income." Hard work
during the next four years will be required of every one oT
you; indeed, your time will be so occupied and your mental
powers so strenuously engaged that you will have but little
opportunity for recreation or for the amenities of life. But
while this is the most difB.cult period of your career as far as
intellectual work is concerned, do not, I beg of you, forget
altogether the man in the making of the physician or surgeon.
However much your instructors may stimulate you, however
much work they may ask you to do, you will be wise if you
retain some period of the day, be it only half an hour or even
less, when you can withdraw from men and medicine and in
some quiet nook indulge a wholesome longing for good gen-
eral literature. Keep your old friends by you — your Plato
and Marcus Aurelius, your Emerson, Carlyle, your Dante,
Shakespeare and Milton, your Goethe, Shelley and Keats.
If your osteological studies prove refractory you may find
the stoicism of Epictetus a remedy for your disturbed
spirit; after the depressive influences of pathological anat-
omy the lyric of Goethe, the raptures of Shelley, or an
essay of Stevenson may prove to be uplifting; to combat the
intoxicating fumes of the chemical laboratory try the anti-
dotal effects of Burton, of Sterne or of Eabelais. The time
so spent will not only be revivifying for the moment, but
will be of the greatest value to you in your professional life
after graduation. Skill is more and more reverenced, but
skill without culture has lost half its power. And culture,
like reputation, has not only to be gained but to be kept,
nor is it gained or kept without cfTort, without constant
vigilance.

Permit me to hope that you have laid broad foundations in
the sciences which arc fundamental for medicine; viz.:
physics, chemistry and biology. Without thorough training
in these it is impossible to keep abreast of the rapidly swelling
tide of discovery in modern medicine. If, further, you are
familiar with the French and German languages you will
find it possible to become conversant with important new
facts and discoveries months and sometimes years before they
enter into the English text-books. Of the distinctly medical
sciences, anatomy, physiology and physiological chemistry,
together with pathology, form the framework upon which all
the rest of the medical sciences are built. Failure to make
this framework solid renders the superstructure inevitably
unsafe. Do not forget that the medicine of to-day differs
from that of the years close behind us chiefly in the substitu-
tion of "handcraft" for much of the former "redecraft."
In these days, too, as it has well been put: '' The eye cannot
say unto the head, I have no need of thee." Instead of
accepting the statements of others about things as of yore
the medical student is nowadays being made to do things.
Instead of memorizing text-books, quiz compends and lecture
notes, he is more and more required to study the natural
objects, to observe accurately, to record concisely and ade-
quately, to experiment intelligently. While good lectures,
good recitations and good text-books still have their place,
the student is wisely encouraged to interrogate Nature for
himself and to believe in the replies he obtains from her
rather than to put implicit confidence in the descriptions of
others.

The new methods of medical education arc costly; they
demand large laboratories, expensive equipment and scientifi-
cally trained instructors. They cannot be satisfactorily in-
troduced into schools where the sole income is derived from
the fees of students; large endowments are absolutely essen-
tial for the proper carrying out of the plan.

Finally, gentlemen, let me give expression to the hope that
among this class now entering, besides the large number who
will go on into beneficent and successful practice, there may
be some who, willing to scorn delights, to live laborious days,
will set before them the high hope of making actual additions
to knowledge. It is not fair that we should accept the gifts
of our forerunners without making the effort ourselves to
enrich the general stock of knowledge. The paths of inves-
tigation are not smooth; the way of research is difficult. But
the goal is strife-worthy, and the rewards are sufficient.

In closing then let me quote those stirring words of the
sage of Chelsea, which I excerpt from his Sartor Eesartus.

"Produce! Produce! Were it but the pitifulest infinitesi-
mal fraction of a Product, produce it in God's name! 'Tis
the utmost thou hast in thee: out with it then. Up, up!
Whatsoever thy hand findeth to do, do it with thy whole
might. Work while it is called To-day, fur the night comctli,
wherein no man can work! "

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

ON THE OCCURRENCE OF TAILS IN MAN, WITH A DESCRIPTION OF THE CASE REPORTED

BY DR. WATSON.

By Eoss Granville Harrison, Ph. D., M. D.,
Associate Professor of Anatomy, Johns IIopMns University.

Some years ago Bartels' gave an excellent resume of onr
knowledge and beliefs concerning the occurrence of caudal
appendages in man, showing that references to this peculiar-
ity are to be found as far back as the writings of Pliny and
Pausanias. Appended to Bartels' paper is a map, which
shows the various lands supposed at one time or other to have
been the haunts of human races with tails. These regions
include not only widely distant portions of South America,
Asia and Africa.- but also the greater part of western Europe.
While numy of the statements cited by Bartels are to be
classed as legendary, it is of interest to note how persistent
and wide in range the belief in the existence of such races
has been. The most remarkable stories have been told and
have found credence; in these the significance of the caudal
appendages has been variously interpreted. On the one hand,
a tail has been considered a distinction of the highest degree,
even a mark of divine descent, as in the case of the Kanas of
Poorbunder; ' on the other hand, it has usually been looked
upon as a curse or a stigma of degradation.'

While cai-eful investigation of the many travellers' stories
has invariably given negative results regarding the existence
of tailed races, so many individual instances of homo caiulatus
have been observed, that the popular belief in them has been
kept alive without difficulty. With the growing interest shown
by anatomists and anthropologists in the subject, the number
of cases which have been reported has become considerable,
and the fact that the human embryo at a certain period of de-
velopment is provided with a tail-like appendage has lent
color to the discussion of the question. Bartels in 1884
referred to one hundred and sixteen persons who had recorded
observations upon tailed men. Of these, over sixty cases had
been more or less completely described. In 1892 Schaeffer''
collected additional cases, adding in all twenty-five. Pyat-

' M. Bartels: Die geschwUuzteu Mensclien. Arcliiv f. Aiitliropol., B<1.
XV, 1884.

5 These were the rulers of the Jaitwa or Camari, one of the Rajpoot
tribes. "They trace their descent from the monkey-god Ilauuman, and
confirm it by alleging the elongation of the spine of their princes, who
bear the epithet 'Pooncheria, or the long-tailed Ranas of Saurashtra.' " —
James Tod: Annals and Antiquities of 'Rajasfhau, or the Central and
Western R.ajpoot States of India, vol. i, Loudon 1839.

3 Bartels cites an instance of this in the stories regarding a certain
community of tailed men in Turkestan. These were held in the utmost
contempt by the other people, and were therefore condemned to con-
stant inbreeding. They were referred to as "Kuju rukly Tatar," which
in German is rendered " Stiitkendes ZIhgeziefer mil Schwanzen." The tail
was supposed to be a special curse in that it hindered the possessor
from sitting properly on his horse.

^Oskar SchaefTer: Beitrag ?.ur Aetiologie der Schwauzbildungen beim
Menscheu. Archiv f. Anthropol., Bd. xx, 1833.

nitski ' has also given an elaborate account of the subject,
and still more recently Kohlbrugge," in connection with an
admirable description of a very interesting case, has made
valuable comparisons with previous work. From the United
States five cases have, to my knowledge, been reported.'

Undoubtedly we have in these so-called tails a most hetero-
geneous collection of anomalies. Anything appended to the
sacral or coccygeal region is described as a tail. Many do
actually bear certain resemblances to the tails of lower ani-
mals, and have in fact been compared with a great variety of
these. On the other hand, some are vesicular or of irregular
shape and accompany the condition of spina bifida, while
others are to be classed as teratomata or other tumors. A
further very significant fact is that a large proportion of the
eases have been complicated by the coexistence of ectopia
viscerum, hypospadia, atresia ani, or deformities of the limbs,
all of which are known to result from amniotic adhesions.
This circumstance has led Schaeffer to the conclusion that
human caudal appendages are always due to this cause.'

There are, however, a great many cases in which the ana-
tomical relations of the tail are such as to indicate that it
owes its existence to the persistence of at least part of the
vestigeal tail found in the human embryo. In some of these
it seems that the coccyx extends down into the tail, though
there is no good evidence that there is ever an increase over
the normal number of coccygeal vertebrae in these instances.
Under this latter head would come the majority of the adher-
ent (angewachsene) tails described by Bartels,' and also some

5 1, S. Pyatnitski : On the Question of the Formation of a Tail in Man,
and of Human T.ails in General, according to Data from Literature and
Personal Researches. Dissertation. St. Petersburg, 1893 (Russian).

« J. H. F. Kolilhrugge: Schwanzbildung und Steissdriise des Menschen
nnd das Gesetz der Riichscklagsvererburg. Natuurkundig Tijdschrift
voor Nederlandsch-Indic, Deel Ivii, 1S9S.

'Dickinson: A Child with a Tail. Brooklyn Medical .lournal, vol.
viii, 1894.

Halsted Myers: j\ Caudal Appendage. Proceedings of the New Tork
Pathological Society, (1893) 1894.

Julian Berry: Baby with a Tail. Memphis Medical Journal, vol. xiv,
1894.

A. Ecker: Der Steisshaarwirbel (vertex coccygeus), die Steissbeiu-
glatze (glabella coceygea) und das Steissbeingriibchen (foveolacoccygea),
wahrscbeiuliche Ueberbleibsel embryonaler Formen, in der Steissbein-
gegend beira ungeboreuen, neugeborenen und erwachsonen Menschen.
Archiv f. Anthropol., Bd. xii, 1880. Ecker describes a case reported to
him in a letter from Dr. Neumayer, of Cincinnati.

Miller: Medical and Surgical Reporter, 1881. (Not accessible.)

8 Archiv f. Anthropol. Bd. xx, p. 319.

' M. Bartels: Ueber Menschenschwanze. Archiv f. .Anthropol., Bd.
xiii, 1881. In this paper Bartels classifies persistent tails, dividing them
into two main types, adherent and freely suspended (/roV) ; of the latter

April-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

cases in which the tail projects free from the trunk as, for
instance, cases described by Brann,'° Ornstein," and by Dick-
inson. The majority of the embryonic tails contain, liow-
ever, no prolongation of the vertebral column but are classed
as what Virchow"' calls soft tails (weirhe Schivdnze).

Description of Case.

Abont a year ago Dr. Watson exhibited before the Johns
Hopkins Hospital Medical Society a baby with a tail, which is
an example of the last-named class." The tail was removed
later, and through the kindness of Dr. Watson, who gave me
the specimen as well as his notes of the case, I am enabled to
make a fairly complete report on it, including a description
of its histological structure.

The child, which was (lie tliird in the family, was a healthy,
well-developed male. In its family history there is nothing
which throws any light upon the case. Aside from the tail
the baby presented only one other slight deformity, and that
was in the four outer toes of the right foot. These toes were
shorter than the normal ones of the left foot, their tips were
turned up and the nails were small and thick. Tlie phalanges
of these toes were short and there were but two in each toe.
The great toe of this foot was normally developed.

The tail appendage was attached in the mid-line about one
centimeter below the tip of the coccyx. Examination of the
saero-coccygeal region showed a well marked foveola coccygca
(Eeker) (Figs. 1 and 3), but owing to the extreme fineness
of the hairs of this region, which to the unaided eye were
quite invisible, it was impossible to distinguish any particular
coccygeal bald spot or glabella coccygea (Ecker). Beginning
a little to the right and below the foveola is a sharply defined
groove, which runs obliquely downward and to the left be-
tween the buttocks and passes to the left of the root of the
tail.

The appendage itself was of firm consistency, thougli con-
taining no bone. It was covered with normal skin, contain-
ing fine hairs, and was apparently well vascularized. Three
distinct portions or segments could l)o made out. The basal
piece was short and on the dorsal side scarcely marked off
from the next following, except when the tail was in a state
of contraction (Fig. 2). On the ventral side a transverse
furrow separated it from the next portion. The middle seg-
ment had a length of 2-5 mm., was curved a little to the right
and tapered somewhat towards its distal end, where the much
more slender end-segment was attached. These two portions
were separated by a constriction more marked on the left side.

a number of subdivisions are made, between wliiob, bovvever, tbc distinc-
tion does not seem to me to be sharp.

•0 M. Braun; Ueber rudimentiire Scbwauzbildung bei eiuem erwacb-
senen .\Iunschen. Arcliiv. f. Autbropol., Bd. xiii, 1881.

"Ornstein: Scliwauzbildnng beim Menschen. Archiv f. Antlimpol.,
Bd. xiii, 1881.

'2 R. Virchow : Sebwaiizbilduni^ beim Meusclion. Deutsche uied. Wocii-
enschr., 10. Jahrg., 1884.

'3 W. T. Watson: Exhibition of a Three-nxintlis' Infant with a Caudal
Appendage. Proc. J. H. II. Med. Soc. Johns Ilopl^ins Hospital Bulletin,
vol. xi, 1900.

The terminal segment curved to the right and ventrally and
ended in a rounded blunt extremity. On the whole, the tail
gave an impression not unlike that of a pig's tail, a similarity
which has been noted' in a number of cases previously re-
ported.

The hairs upon the tail, which were considerable in num-
ber, were plainly visible to the unaided eye. They pointed
towards the tip, as could readily be confirmed by examination
of longitudinal sections (Fig. 4). The convergence of the
hairs towards the tip of the tail corresponds with the arrange-
ment of the hairs in the coccygeal whorl {vertex coccygeus of
Ecker), found in normal, i. e. tailless individuals, and sup-
posed to be a vestige of the embryonic tail.

Two weeks after the birtli of the child the tail was 4.4 cm.
long; at the age of two months it had gi'own to 5 cm.; and at
six months, when it was removed, it had attained the length
of 7.0 cm., showing altogether a fairly rapid rate of growth.

The most remarkable characteristic of the tail was its
movability. When at rest it would lie extended in the mid-
line (Fig. 1), or bent over to one side upon the buttocks.
The mother of the child said that she had seen the tail bent
through an angle of 180°, its tip pointing towards the head.
It must, however, have been brought into this position pas-
sively, for, as will be seen later, there was nothing in the
arrangement of its muscles which could account for this.
When the child was irritated, and cried or coughed, the tail
would contract markedly. Between the basal and middle
segments but little movement was ]50ssible; the contraction
of the muscles merely brought out the constriction between
tlie two portions more plainly. Between the middle and
distal segments the movement was considerable. The latter
could be drawn in sharply, telescoping the middle segment,
and at the same time flexion to the left side took place.
During this action the middle segment became much shorter
and thicker.

When the child was about six months old the tail was
removed by Dr. Watson.'* The amputated appendage was
put immediately into Zenker's fluid to harden. After it had
been washed and kept in strong alcohol for some time it
measured 5.3 cm. in length. It was then cut into four pieces
with a sharp razor, and the pieces were imbedded in celloidin.
Cross sections were cut at three different levels, near the
base, proximal to the second joint, and near to the tip, as is
indicated in Fig. 4. After a few transverse sections were
cut off, the pieces were stuck together and reirabedded in
celloidin for the purpose of cutting longitudinal sections of
the whole.

From the study of sections it is seen that the skin covering
the whole of the tail except a limited area on the ventral sur-

" It seemed advisable to remove the tail, not only in order to accede
to tbc wishes of the child's parents, who regarded its presence with
chagrin, but also on more practical grounds. It loolied as if the tail
might become the seat of a troublesome iutertrigo. Besides, its rate of
growth was considerable, and it did not seem unlikely that the
appendage might have later attained undue proportions, causing, as has
been reported in several instances, considerable inconvenience in sitting.
(See Lissner: Virchow's Archiv, Bd. 99, 188.5.

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

face is of normal stnicture. The layers of the epidermis are
easily distinguishable. The thickness of the skin varies some-
what. Near the base of the tail on the ventral side it is
found to be quite 2 mm. thick, while on the dorsal surface of
tiie same jjortion it is scarcely 1.5 mm. Further out, i. c. at
the middle cut (Fig. 4, a), there is the same difference in
thickness between skin of the ventral and dorsal surface
(Fig. 5), although the skin is here not quite so thick as at
the base. Near the tip the thickness throughout the whole
circumference is nearly 1.5 mm. The greater thickness of
the skin on the ventral side at the base is due principally
to the epidermis, the eoriuni being more nearly uniform
throughout. In the thickened area the epidermal ridges ex-
tend down deep into the cutis, and the papillse are very long
and slender. The various integumentary organs, sweat glands,
sebaceous glands and hairs, are numerous and of normal
build. In longitudinal sections (Fig. 4) it may be very plainly
seen that the hair follicles are obliquely inserted, the hair
pointing towards the tip of the appendage. This is with-
out exception the case in the proximal two-thirds of the tail,
although the regular arrangement is somewhat disturbed at
the crease where the distal and middle segments join, especi-
ally on the left side. The corium contains a very abundant
supply of elastic fibres which may be readily demonstrated in
sections stained by Weigert's method.

Beneath the skin the main bulk of the tail is made up of
areolar tissue containing much fat. Blood-vessels, nerves,
and striated muscle fibres are imbedded in this mass. There
is no trace of anything like the medullary cord or of noto-
ehordal tissue, as Gerlach found in the tail of a fcetus of four
months.

The voluntary muscle consists of a few bixndles of fibres
which take origin from the subcutaneous areolar tissue near
the proximal end of the middle segment. They lie on the
left side not far from the mid-line (Figs. 4 and 5), and run
distally in parallel bundles diverging somewhat towards
their insertion in the skin just beyond the joint between the
middle and distal segments. The majority of the fibres are
attached on the left side; a few, however, pass to the skin of
the right side; and others are attached to the dorsal surface,
and perhaps a few ventrally. The action of the muscle is
thus clearly explained by its anatomical relations. There
are no muscle fibres running between the trimk and the tail.

On the right side near the middle of the tail there are a
few muscle fibres (Fig. 5, M'), but these are isolated in small
bundles or as single fibres by a dense stroma of connective
tissue. Moreover, nearly all of these fibres are in a state of
degeneration. The fibrils are less distinct than usual, and
the nuclei may be found scattered throughout the substance
of the fibres. The muscle is, in fact, in an advanced stage of
simple atrophy.

No one of the blood-vessels stands out preeminently in
size. The largest artery is on the left side, held in place by
strong connective-tissue bundles. This may be seen in sec-
tions through the middle (Fig. 5, A), as well as through the
base of the tail. There are several smaller vessels in the

vicinity. Two .'=niall arteries are seen in the riglit dorsal
quadrant near the centre and one just beneath the curium,
to the left of the mid-line. The veins are small and incon-
spicuous. There is nothing to be seen of a tuft-like branch-
ing of the vessels as Virchow " describes in one of his cases,
nor is there anything resembling erectile tissue.'" There is,
however, an abimdant supply of blood-vessels in the corium.

A number of small nerve trunks (Fig. 5, N) run longitu-
dinally in the areolar tissue of the appendage. The majority
of these accompany blood-vessels.

Similar Cases. — While it is not practicable to enumerate
here all of the similar cases which have hitherto been re-
ported, there axe some which for one reason or other are of
especial interest. The tail of a Moi," ten years of age, which
had attained the length of over twenty-five centimeters, is
interesting on account of its size. Many of the cases have
been described very briefly and only as regards external ap-
pearance. There are, however, a number of cases which have
cither been dissected or examined microscopically. These
include Grove's case described by Virchow," and cases re-
ported by Meyers,'" Vinogradow,"" Eodenacker "' and Schebold-
ayeff," all of which agree with the present case in general
structure but differ from it in the absence of muscle. In
two other cases, however, described by Pyatnitzki "" and Ger-
lach,''* respectively, striated muscle fibres were found, and it is
to be assumed that such tissue was present in Neumayer's
ease, for the tail in this instance could be excited to reflex
contraction by stimulation of the sacral region. The compli-
cated arrangement of the muscles found in some instances is
associated with the occurrence of bone, as in the case de-
scribed by Hennig and Eauber,"" and especially in Kohl-
brugge's case.'" The tail described by Gerlach in a foetus of
4.6 cm. also contained a continuation of the notochord, which
has as yet never been seen in older subjects.

The Tail in the Human Embryo.

The caudal region in human and other mammalian embryos
has already been described by Ecker, His, Keibel, Fol, Braun
and others. These accounts, while agreeing in the main,
bring out considerable difl'erences of opinion as to details.
For this reason I give here a further description of the tail

'5 Virchow' s Archiv, Bd. 7il, 1880.

"Bai'tels; Archiv f. Antliropol., Bd. xv, p. 116.

1' Candiil Appeudage in Man. (From tlie French of I^ticnne Rabaud,
iu " La Naturaliste.") Scientittc American, vol. 50, 18S9.

18 Virchow's Archiv, Bd. 79, 1880.

'9 Proc. N. T. Pathol. Soc, 1893.

•" K. N. Vinogradow : On Human Tails. Vrach, vol. sv, 1894 (Russian).

■-' G. Rodenacker: Ueber den Saugethierschwanz mit besonderer
Beriicksichtigung der caudaleu Anhiinge des Menschen. Inaug.-Diss.,
Freiburg i. Br,, 1898.

22 W. Scheboldayeff : Tailed Men. Zemsk. Vracb, vol. vi, 1893 (Russian).

■"luang.-Diss., St. Petersburg, 1893.

S'' L. Gerlach : Ein Fall von Schwanzbildung bei einem menscMicheu
Embryo., Morphol. Jahrb., Bd, vi, 1880.

■5 C. Hennig and A. Rauber: Ein neuer Fall von geschwiinztem Men-
schen. Virchow's Archiv, Bd. 105, 188G.

■■« Natuurkund. Tijdschr. v. Ned. Indiii, Deel. Ivii, 1898.

April-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

region in several human embryos. This I nm enabled to do
tlirough the kindness of Dr. Mall, who placed at my disposal
his fine collection of human embryos. Two specimens, four-
teen and sixteen millimeters long respectively, were found to
be especially adapted for this purpose, for it is at this stage
that the tail reaches the highest point in its development.
The study of these was greatly facilitated on account of their
excellent state of preservation, and by the fact that they were
cut into perfect series of sagittal sections.

Embryo m. Greatest Length IJi mm. : N eck-Breech 12 mm.
— The tail of this embryo is marked oft' vcntrally by a fold of
epithelium which extends eranially from the anus, forming a
shallow pit or crease between the anal prominence and the
tail. This fold extends to the level of the cranial end of the
tliirty-third vertebra (Fig. 6), so that from this point on, i. c.
distal to the third coccygeal vertebra, the caudal end of the
embryo projects free from the trunk.

The vertebral column extends throughout but half the
length of the tail, in which, therefore, a vertoliral and non-
vertebral portion may be distinguished.

The terminal portion of the tail or caudal filament is bent
dorsally and inclined to the left side, and becoming rapidly
thinner distally, ends in a slight knob-like enlargement,
which is scarcely shown in the figure. The most conspicuous
structure in the caudal filament is the medullary cord, which
runs to the tip and there ends in a vesicular enlargement.
Tlie notochord and the terminal branches of the aorta and
inferior vena cava also extend out into it though not so far
as the medullary cord. The filament is supported by a dif-
fuse mesenchymatous network, more concentrated in the
ventral side just beneath the integument, which is perhaps
an indication of the remains of the post-anal gut found in
younger embryos.

Counting from the atlas down, it is clear that there are in
all thirty-six vertebrae present, of which the distal seven be-
long to the coccygeal or caudal region. In the trunk, down
tlirough the sacral region, the vertebral bodies are composed
of embryonic cartilage, which does not stain intensely. The
intervertebral discs, owing to the greater concentration of
the cells composing them, stand oiit in sections as deeply
staining bands. Between the vertebral bodies and the discs
there is a zone of cells, which stains more intensely than the
cartilage and less so than the discs. In the well advanced
vertebrffi of the lumbar region the intermediate zone is thin
and clearly forms a part of the perichondrium of the vertebral
cartilages. Beginning with the first coccygeal vertebra this
intermediate or periehondrial layer forms a thick pad, especi-
ally on the distal surface of the disc. The vertebral body is
licre proportionately thin, showing itself merely as a lighter
streak between the more deeply staining perichondrium of
each end. In fact the bodies of the distal coccygeal vertebra;
can hardly be spoken of as cartilaginous. In thickness (cranio-
caudal) the vertebral bodies diminish steadily throughout the
sacral and coccygeal regions, but there is very little diminu-
tion in the dorsoventraLdiameter xmtil the thirty-fourth verte-
bra is reached. The last three diminish rapidly towards the

tip. In the last two the discs are fully as thick as the verte-
bral bodies themselves. The distal surface of the vertebra is
capped by a well marked disc. There is on each side of the
intervertebral discs in the coccygeal region a small mass of
deeply staining tissue, which projects ventrally and laterally.
They are visible only in sections which pass to the side of the
mid-line. They represent undoubtedly rudimentary hypa-
pophyses or hajmal arches found in the caudal vertcbrse of
lower forms.

The spinal ganglia, not counting the ganglion of the bypo-
glossus, are thirty-three in number. In connection with the '
last a distinct ventral ramus arises and passes ventrally to
the side of the vertebrre, bending distally; ventral to the
vertebra; it joins a trunk from the next higher nerve. Its
mode of ending is uncertain.

The number of muscle plates could not be made out clearly.

In the interval between the thirty-first and thirty-second
vertebrffi the medullary cord (med.) becomes siaddenly attenu-
ated into a filum terminale. There are apparently few or no
neuroblasts beyond this point; the walls of the tube are made
up of columnar epithelial cells. In the distal portion of the
vertebral region and at the base of the caudal filament the
cord takes a somewhat sinuous course. The central canal
extends to the tip of the tail, where it ends in the slight
enlargment mentioned above, the terminal ventricle.

The notochord {cli.) forms the axis of the vertebral bodies
and discs, and in the proximal portion of the coccygeal region,
as in the trunk, is almost straight. In the region of the last
two or three vertebra' it is more tortuous. It leaves the
vertebral column near the dorsal surface of the last vertebral
body and passes thence dorsally to the ventral side of the
medullary cord, accompanying this nearly to the tip. In
contrast to the vertebral portion, the terminal portion is
scarcely differentiated and not well defined in the surround-
ing mesenchyme.

The continuation of the aorta {ao.), i. e. the a. sacralis
media, at first ventral to the vcrtebraj, passes out into the
caudal filament as an a. caudalis. From this are given off
the segmental arteries, one for each vci-tebra down to and
including the last or thirty-sixth. (The last two are not
shown in the figure.) These pass up on each side of the
vertebral bodies, but it is doubtful if the more distal ones arc
as yet fully open. In the same way the vena cava continues
into the tail, as the v. sacralis media and the v. caudalis, which
lies ventral and to the right of the artery. At their termina-
tion in the caudal filament the artery and the vein meet. The
vein is of largo calibre to the region of tlie thirty-second
vertelira; here it narrows down very suddenly. There are
numerous small blood-vessels throughout the mesenchyme
of the tail.

Embryo JfS. Greatest Length 16 mm.; Neck-Breecli Jjength
IJi mm. — The relations of the tail to the trunk are about the
same as in the younger embryo first described, ?'. e. it is free
from tlie thirty-third vertebra on.

The vertebral portion of the tail is longer, but the caudal

100

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

filament is shorter and more shrunken. It bends sharply on
itself to the dorsal side, almost through an angle of 180°.

Thirty-seven vertebrae are present, with possible indications
of a thirty-eighth; eight of these belong beyond doubt to the
coccygeal region. The thirty-foTirth and thirty-fifth are
partly fused in the middle. The hypapophyses of each are
distinct.

The spinal ganglia number thirty-two. The relations of
the notochord, medullary cord and blood-vessels are the same
as in the embryo first described. There is a slight irregularity
in the notochord in the form of a process wdiich extends
ventrally into the substance of the thirty-sixth vertebra.

General Consideeations.

Ecker" and His'' were the first to give detailed descrip-
tions of the caudal region of the human embryo. Their con-
clusions regarding its definition and ultimate development
may be taken as the starting point in the discussion of the
subject. The agi-eemeut reached by Ecker and His may be
rendered in part as follows:'" (1) The term "tail" may be
applied only to that portion of the embryo which projects
free beyond the cloaca. (2) The tail consists of a portion
containing vertebrae and a portion without vertebra3 (caudal
tUament). The latter contains only notochord and medullary
cord. (3) Only the non-vertebral portion atrophies. The
vertebral portion remains for some time as the coccygeal
prominence (Sleisshbchcr), which, however, gradually disap-
pears in consequence of the increase in the curvature of the
sacrum and coccyx, and of the progressive development of
the pelvic girdle and its musculature.

Two matters which have a bearing upon the morphological
significance of the ])crsisting caudal appendages in man are
brought up in the above for consideration. The one concerns
the structure of the tail in the human embryo in comparison
with the tail in lower forms; the other is the nature and
amount of regressive change which takes place in the human
tail during development.

Regarding the first, Keibel " discovered an additional fact
(if importance in the presence of a post-anal gut in the human
embryo. Braun's" observations on' the caudal filament of
mammalian and bird embryos are of importance in showing
that the caudal filament is of general occurrence and not a
]ieculiarity of the human tail. Again, the occurrence of
spinal nerves and ganglia in a number of the coccygeal seg-

■-'' A. Ecker: Archiv f. Aiitbroiiol., Bil. xii, ISSO.

A. Ecker: Besitzt der menscliliche Emliiyo eiuen Scbwanz? Archiv
f. Anat. n. Physiol, auat. Abtheil., ISSO.

ss W. His: Anatomie mensclilicher Embryoneii, I, Leipzig, 1880.

W. His: Ueber den Schwanztheil des menscblieben Embryo. Archiv
f. Anat. u. Physiol, anat. AbtheiL, 1880.

-9 A. Ecker: Replik und compromissitzc nebst Scblusserkarung von
W. His. Archiv f. Anat. u. Physiol, anat. AbtheiL, ISSO.

*' Fr. Kevbel : Ueber den Scbwanz des menschliclien Embryo. Archiv
f. Anat. u. Physiol, anat. AbthieL, 1891.

31 M. Braun: Eutwicklungsvorgantre am Schwanzende bci eiuigen
Siiugethiereu mit Beriicksicbtigung der Verhiiltuisse beim Menschen.
Archiv f. Anat. u. Phys. anat. AbtheiL, 1883.

ments, as shown by Fol," Phisalix '^ and Keibel, the continu-
ation of the aorta and vena cava into the caudal filament,
together with the presence of segmental arteries and the
hypapophyses or rudimentary hjemal arches in all of the
coccygeal segments as described in the present paper, show
that the caudal region of the human embryo resembles that
of other mammalian embryos in all respects except in size and
in the number of its segments.

Concerning the regressive development of the tail consid-
erable difference of opinion has been expressed. Rosenberg,
who holds that, strictly speaking, the caudal rudiment in man
is not the homologue of the tail of other animals, but is the
result of a precocious growth of the medullary cord," con-
siders that the appendage disappears in consequence of the
increase in volume of that end of the embryonic body and
not through absorption. His,'" in supporting Rosenberg,
makes the statement that no reduction in the number of seg-
ments takes place during the development of the human
embryo, but that the regressive changes are confined to the
caudal filament; this view is confirmed in the agreement with
Ecker. On the other hand, Fol and Phisalix find thirty-eight
segments in embryos of 8-10 mm., with indications that sev-
eral of these disappear through fusion in the course of devel-
opment. Allowing for the- possibility that these observers
have counted in an occipital segment, there would be in
embryos of this size at least thirty-seven trunk segments,
which would correspond to thirty-six vertebra3. Keibel finds
in an embryo of 8 mm. thirty-five trunk segments, together
with a mass of unsegmentcd mesoderm, equaling two seg-
ments in length. Reckoning this as two instead of one seg-
ment, as Keibel does, we have again thirty-seven segment.^,
corresponding to thirty-six vertebrae.

The following is an attempt to tabulate the number of
segments found in embryos varying in length from 7.5 to
21.5 mm. With the exception of the last column the data
are as recorded by the observers themselves. In the last
column the number of vertebrse is given which would corre-
spond to the total number of segments after certain changes
have been made, such as deduction of occipital segments or
addition of unsegmented mesoderm, which seemed justified by
the descriptions of the authors.

3- H. Fol: Sur la queue dc rciubryon humain. Comptes Reudus, T.
100, Paris, 188.5.

33 C. Phisalix: Etude d'uu embryon humain de ID milliniotres. Ar-
chives de Zool. Exp. et Gen. II"" S., T. vi, ISSS.

■» E. Rosenberg: Ueber die Eutwickeluug der Wirbelsaule und das
centrale carpi des Menschen. Morphol. Jahrb., Bd. i, 187G. "... dass
die Gestaltung des hinteren Lcibesendes ebeutalls von dem MeduUa-
rohr derart beeinflusst wird, dass letzteres, indem es in seinem Liingen-
wachsthnm dem der anderen, un der Zusammensetzuug des hinteren
Lcibesendes Theilhabenden Bestandtheile vorauseilt, an demselben
eiuen Vorspruug erzengt. ..." p. 138.

35 " Es werdeu demnach beim menscblieben Embryo keine iiberzahligen
zur Riickbildung bestimmten Segmeute augelegt." Auatomie men-
schlicher Embryonen, i, p. 93.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XVII.

Fi(i. 1. — I'liotnf;raiiU sliDWiiii;' tail ill exteiuleil cuiuliticiii.

Fiu. 2. — Pliutuyrapli sliowini;' tail in state of ccjiitractioii.

Fig. ;!. — PiKitof^iapli sliowinu; tlie ventral surface of tail.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XVIII.

--M

Fin. 4. — Frontal sections of tail, showing
the arranifcnient of the muscle tibres (.V).
a. Place from whicli the cross-section repre-
sented in Fii;. .5 was taken. x 3.

W/i/i\tl

Fig. .5, — Cross-section through the middle of the tail (Fig. 4, a). M,
iinisclc; J/', degenerating muscle ; .1, artery; jV, nerve; i is jilaced on
the left and It on the right of the apiicndage. x SI.

Hari-ison del.

Fig. (i. — Caudal region of embryo of 14 nun. (No. 144 of Dr. Mall's
collection), combined from several sagittal sections. An.^ auus; .lo.,
caudal aorta (.1. sncn/?«s Bi«?ia) ; ^'oi. ,/r7., caudal lilament; CA., notochord;
ilcd., medullary cord ; S. iii/., ximix iiroi/eiiilulis : I'. :i:i, third coccygeal
vertebra; ;i(i, seventh coccygeal vertebra; V. c. i'., caudal portion of fena
ctnut ivffflor ( P. ann-aUs mcfjia}. x 1)1.

April-May-June, 1901.

JOHNS HOPKINS HOSPITAL BULLETIN.

101

Observer.

Longtli

of embryo

in mm.

Seg-meuts
in mes-
oderm.

Spinal
gjinglia.

Correspoudinj?

numlier of

Vertebnu. Aertel)nr after

allowing for

corrections.

His 7..5

Keibel S.O*

Fol S.0-9.0

Phisalix 10.0

Keibel 11.5*

Fol 13.0

Harrison . . . 14.0

Harrison ... 16

His 16.0

Rosenberg. . 16.5

Fol 19.0

Rosenberg . . 19.6

His 21.5

S.'i -

35 _L uiiseEmeiited

meaoderni.

38 —

38 SG

35 _|_ uueeKnienteil 34
meHcideriii.

35
36
36
37
34
33
34
35
34

36+

* Neck-breech measurement.

t Counting the terminal mesoderm as criui\'aleiit to two segments.

From this it may be seen that the number of vertebrae or
their equivalent is fairly if not quite constant in embryos
between eight and sixteen millimeters in length. We have,
then, seven vertebrae in the embryonic tail at its highest
period of development. The stages studied by His and by
Eosenberg were either too young or too far advanced to
show the maximum number of vertebrae. That the reduction
takes place by fusion, as is maintained by Fol, is confirmed
by the study of the embryos described above. In the older
embryo (16 mm.), in which an exceptionally large number
of segments was present, partial fusion between several of
the adjacent vertebrse had taken place. In still older embryos,
as seen in the table, the number of segments is inconstant;
most probably this is due to the varying extent to which
fusion has taken place, though it is possible that it may be
due in part to a difference in the original number. As Stein-
bach ■" shows, the usual number of segments is thirty-four,
i. e. five coccygeal, although the number may be less or, in
I'are instances, even increased by one.

The spinal ganglia of the caudal region, as Keibel has
shown, also suffer reduction. There are never quite so many
ganglia developed as vertebrse, and the last ones are always
more or less rudimentary; but there are always more formed
than persist in the adult. For instance, in an embryo of 10
mm. Phisalix described thirty-six ganglia; in an embryo of
11.5 mm. Keibel found thirty-four; in the embryo of 14 mm.
described above there were thirty-three, and in the embryo
of 16 mm. thirty-two, while in the adult there are but thirty-
one. The segmental arteries of the distal caudal segments
also become obliterated as development proceeds.

We conclude, then, with Keibel that, while as far as out-
ward form is concerned the embryonic tail disappears largely
as a result of the growth of the extremities and the gluteal
region, a certain amount of regressive change takes place in
the caudal appendage itself. This is manifest not only in the

3« E. Steinbach : Die zabl der CiUidalwirbel beim Mensolieu.
mss., Berlin, 1S89.

luaut;

absorption of the caudal filament, as supposed by Ecker and
His, but also in the reduction of all essential structures of
the vertebral portion of the tail, i. e. the vertebrae, muscle
segments, spinal ganglia and blood-vessels. It is interesting
to note that in this tendency to reduction the resemblance
between human and other mammalian tails also holds. The
caudal filament, as Braun has shown, is present in other
embryos and atrophies as development proceeds. The ten-
dency to fusion of the distal vertebra? has been observed in
the embryos of various long-tailed animals. And in short-
tailed varieties, as Bonnet has shown, this tendency is merely
accentuated."

The view that a great many of the anomalous caudal appen-
dages found in man are, as stated in the beginning, due to the
persistence of the embryonic tail, is warranted by the facts
gathered both from the study of the former as well as of the
latter. Many of the differences in form are explained by the
hypothesis of Bartels that tlie embryonic tail may be arrested
in any stage of its development. The soft or boneless tails
are clearly not due to the multiplication of vertebra; or even
to the persistence of all which are developed in the emluyn,
but, as His ™ first suggested, are to be regarded as persisting
caudal filaments. The usual position of these appendages
as well as their structure support this conclusion. The fact
that they are not always attached exactly over the tip of the
coccyx cannot be regarded as conflicting with this view, for,
as has long been recognized, the curvature in the vertebral
column, especially m the sacral and coccygeal regions, changes
markedly during" development, and the caudal filament not
being firmly united to the tip of the coccyx might easily be
shifted slightly in relation to the latter.

In the action of amniotic adhesions Schaeffer^" has sug-
gested a cause which may undoubtedly bring about the per-
sistence of the caudal filament, for it is a fact that in many,
perhaps in a majority of the cases there are other evidences
of such adhesions having been present, and, as Schaeffer
points out, the caudal region, like other projecting portions
of the embryo, is especially liable to stick to the amnion.
The adhesions are to be regarded, however, merely ns a factor
which may induce the persistence of an otherwise transitory
structure and it does not follow that such persistence is always
the result of adhesions. On the contrary, we find in certain
animals that the caudal filament normally persists. Accord-
ing to Braun, this is probably the origin of the tail-stump,
composed of areolar tissue, found in Inuus pithecus, and simi-
lar apendages are also found sometimes in the Ciiimpansee,
as Eosenberg has described.

" R. Bonnet: Uio Rtiunnudscliw;in/.ii;en Hunde ini llinblich aiif die
Vererbung erworbener EiKeuseliatteii. Zeigler's Beitriine z. path. .\nat.
u. alli;. Pathol., Bd. iv, 18S9.

■'" Anatomie meuschlicher Embryonen, i, p. 95.

™ Archlv f. Anthroiiol., Bd. xx, 1S93, p. 319.

102

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-133-133.

DEVELOPMEIST OF THE PIG'S INTESTINE.

By John Beuce MacCallum, M. T>.,
Assistant in Anatomy, Johns Hopkins University.

By the work of Henke' and of AVeinberg' it was first
shown that the various parts of the human intestine hold a
definite relative position in the body. But it was not until
1897, when the researches of Mall' were published, that this
subject was put on a satisfactory basis. Professor Mall de-
scribed in detail the development of the human intestine, the
protrusion of loops into the cosloni of the umbilical cord and
their return to the general body-cavity. He traced the vari-
ous loops through different stages in their development and
showed that in the human adult these loops are massed to-
gether into definite groups, which maintain a constant posi-
tion in the abdominal cavity.

Merkel,' in his handbook, has considered all the literature
on the subject and has given a description of his own work,
the results of which are in accord with those of Mall.

Dexter " has lately described the development of the intes-
tine of the cat. He finds no definite arrangement of the in-
testinal loops to be present in this animal.

The following notes were made in the study of a consider-
able number of pig's embryos:

Methods and Material.

In this study there was used a series of pig's embryos vary-
ing in length from IS mm. to 13 cm. An attempt was made
to obtain embryos with each stage, showing only the least
possible advance on the one preceding it. In some stages
several embryos from the same uterus were examined in order
to determine the constancy of the loops of intestine in indi-
viduals of the same age. Types chosen from the various large
groups of lower animals were also studied.

The only method used was one of direct dissection. The
embryos were hardened in formalin or alcohol, which rendered
the intestines firm and not easily displaced. The abdominal
cavity was opened and the liver carefully lifted away and
dissected out under water. The Wolfiian body and kidney
were similarly removed. The umbilical cord was then laid
open to expose that part of the coelom which it contained. In
this way the intestines could be well isolated without dis-
turbing them in the least. Starting, then, with the stomach
the various loops were followed and modeled with copper wire.
Tliis could be bent so as to accurately represent the direction
of each loop, and the general position of the loops of wire
could be constantly compared with that of the intestinal loops,
so that very little error could arise. On reaching the anus

'Henke; Arch. f. Anat. uud Pliys. Anat. Abtb., IS'.M, S."89.
5 Weinberg; Internat. Monatsch. f. Anat. und Pliys., xiii Bd., 1896.
2 Mall, F. P. ; Arch. f. Anat. und Entwickeluug. Anat. Abth. Supple-
mentbaud, S. 403, 1807; and Anatom. Anz. Bd. 10, S. 4!)3, 1899.
■•Merkel; Handbuch der Topographischen Anatomic, ii Bd., 1899.
5 Dexter, F. ; Arch. f. Anat, und Phys., Anat. Abth., 1899.

the whole intestine was gone over again starting with the
rectum and ending in the stomach. In this way any error
could be well controlled. The whole model was then com-
pared again with the emljryo to see that the surface coils
corresponded. To aid in drawing and studying these models
the various groups of coils were painted in different colors.
The same method was employed in the study of the lower
animals. In the simpler types, however, the wire models
were unnecessary. In the earliest embryos also the arrange-
ment could be made out perfectly well without modeling.

Description of Dissections.

Until the embryonic pig has reached a length of about
10 mm. there is in every case some part of the intestine in
the umbilical cord. The portion nearest the stomach de-
velops entirely outside the cord; while what corresponds with
the lower end of the ileum, together with the coecum and a
short stretch of the large intestine, remain in the cord until
the stage mentioned above. The part in the neighborhood
of the coecum is the last to leave the cord. All the loops
which develop within the cord belong to the part of the
intestine corresponding in position with the lower end of the
ileum. This develops more slowly than the intra-abdominal
portion of the gut.

In the following descriptions the terms " right " and " left "
refer to the pig's body and not to the figures tlicmselves.
"Anterior" and "posterior" refer to the head and tail ends
respectively; while the terms "dorsal" and "ventral" are
used in their ordinary sense. The figures are all drawn from
the right side of the embryo's body unless otherwise indicated.

Figure 1 represents an early stage in the development of
the pig's embryo, in which tlie intestine consists of a single
loop extending out into the umbilical cord. The embryo
itself is 13 mm. long and the loop in the cord is slightly less
than 3 mm. in length. This loop is somewhat curved with
the concave surface towards the head. As represented in
Fig. 1 the intestine is sharply bent on itself in the cord, and
on its return to the main body-cavity it turns at an acute
angle to form the rectum. I can discover no trace of a
ccecum at this stage other tlian a slight enlargement of the
tube just after it bends in the cord. The arm of the loop
which extends from the stomach into the cord is destined to
give rise to the small intestine; while the arm returning from
the cord to tlie rectum is, roughly speaking, the forerunner of
the large intestine. Several embryos of this size were exam-
ined, and the condition described above found to be constant.

In Fig. 2 there is shown the dissection of a pig's embryo,
18 mm. in length. The loop of intestine extending into the
cord is much like that represented in Fig. 1. A distinct
coecum, however, can be made out in the rectal arm of the

Ai'ril-.May-,Ii-.ve, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

103

loop, a short distance from where the intestine bends on itself.
This coecum is a short blind sac having an appearance very
much like that shown in the iigurc. It will be noticed tliat
a considerable part of the body-cavity is, in this stage, in tlie
umbilical cord. Fully luilf the length of tlie intestine is
contained in this extra-abdominal cielom. Just inside the
main body-cavity a loop is beginning to 1)e formed in the
small intestine. Its bends are marked 1, 'i and .'5. From the
stomach it extends dorsally and to the right. Turning
sharply it runs ventrally and to the left, and lieforo entering
the cord it ))roceeds again posteriorly. On cumparing Figs.
1 and 2, there is seen a greater change in this part of the
intestine near the stomach than in the part contained in the
cord. The large intestine beginning at tliu cnn-um turns and
passes into the rectum as before. Several enibryos of this
size showed an identical structure.

Fig. 3 represents a pig 21 mm. long. The portion of the
intestine in the cord is still unchanged, while that in the
body-cavity jirojier .shows a further development of the same
loops seen in Fig. 2. In comparing the numbers on the two
figures there is no ditficulty in recognizing the corresponding
parts. The ca?eum holds the same relative position as in
Fig. 2. After entering the cord at the loo]) 3 in Fig. 3 the
intestine l)ends in a curve with the concave side towards the
head. It then turns abruptly backward and to the left, and
returns to the main body-cavity by almost the same path.
This is represented i)lainly in Fig 3, and it will lie noticed in
the succeeding stages that this particular arrangement of the
intestine as it turns is quite characteristic.

Fig. 4 shows a somewhat more advanced stage in the
develojnnent. It is drawn from the dissection of a pig 23 mm.
long. The general position of the intestine is very similar to
that just described. The loops, however, have increased in
number; and instead of one entire loop, as represented in
Fig. 3, there are three, indicated by the letters a. h and c in
Fig. 4, B. In Fig. 3 the stomach narrows into the small
intestine, which bends rather aliruptly, and forms one com-
plete loop overlying the large intestine. In Fig. 4 the same
thing occurs, but following this tirst loop are two others.
As shown in the figures there is a tendency for the loops to
grow around the large intestine from the right side. The
large intestine is on the left side of the small intestine and
somewhat anterior. The part of the small intestine contained
in the cord is less changed, and its growth is apparently some-
what slower. There is, however, to be seen the beginning of
a new coil marked x in Fig. 4, B. This is an incompletely-
formed loop and shows well the way in which the loops
develop. It is simply a bending, as though the intestine had
grown too long for the space it was obliged to occupy. Before
reaching the ccecum the small intestine turns on itself in the
characteristic way described in Fig. 3. The large intestine
is unchanged.

In Fig. 5 the same loops are seen in the first part of
the small intestine, and those marked a, b and c correspond
fairly wtII. In the cord, however, there are here too loops
instead of the one shown in Fig. 4. These occur in the small

intestine ojipositc the ccecum and have relatively the same
position as the bending of the tube marked .v in Fig. 4. They
are lettered .v and // in Fig. -5. The remainder of the intestine
is the same as in Fig. 4. The length of this pig was 25 mm.

Fig. (i represents the intestine of a pig of approximately
the same length a? that shown in Fig. 5. The small intes-
tine in the main body-cavity, however, is slightly more ad-
vanced in develo])ment. The various loops can be readily
recognized and niiuli more easily so on the wii'c model than
on the drawing. A very slight change in the general posi-
tion of a loop causes a most decided dilference in a flat draw-
ing. The main difference, for example, between Figs. .5 and
t), is the dislocation of the loop z towards the stomach. By
comjjaring the lettering in the two figures this can be easily
understood. The part of the intestine in the cord is prac-
tically the same in the two figures.

Thus far the large intestine is a simple lube bending
shar])ly near the stomach to form the rectum. 11 will be
noticed that the small intestine has grown much more rapidly
than the large iiitestiiu'; and also that the part of the small
intestine neai' the stomach has increased in length uu:ire rajv
idly than the part in the cord. Several jiigs, the same size
as these last two described, were examined, ami their intes-
tines fomid to be similar in every way. Endiryos tiiken from
the same uterus did not seem to resemble one another in this
respect more closely than pigs of the same length from dif-
ferent uteri.

Fig. 7 represents a dissection of a pig's embryo 28 mm.
in length, and Fig. 8 is a drawing of the wire model made
from this intestine. The stomach, it will be seen, occupies
the same position and narrows into the small intestine in the
same way as before The small intestine here forms a dis-
tinct mass of loops in the nuiin body-cavity, and then extends
out into the cord in a manner identical with that shown in
earlier endiryos. The loops form a cone-shaped mass with
the base of the cone towards the stomach and its apex in the
umbilical cord. This is due to the more rapid growth of that
part of the small intestine near the stomach. This arrange-
ment will be noticed in all the older embryos as well until
after all the coils have returned to the main body-cavity. It
is a little unsatisfactory to attempt to follow the individual
coils of the intestine, and to trace them from one endjryo to
another after their arrangement has reached a complexity as
great as that shown in Fig. 8 and the figures following.
But if the two models represented in Figs 6 and 8 be
compared, there will be seen a certain correspondence
which can hardly be overlooked. The identity of the two
loops in the cord marked .r and // is recognized at first
glance. In this part of the intestine there seems to have
been very little if any change. The coils near the stomach,
however, are distiiutly more complicated in Fig. 8 than in
Fig. 6. The slight bend in Fig. 6 marked e is accentuated
into the loop marked r in Fig. 8. The letters a and z mark
corresponding parts in the two figures; and the loop b can be
readily derived in Fig. 8 from the b in Fig. 6. Following
this, however, there are in Fig. 8 three distinct loops, c, d and

104

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-132-133.

f, without counting x and y; wliile in Fig. 6 there is only one
without considering x and y. At d in Fig. 6 there is the be-
ginning of a new loop, as yet only a slight bending in the
tube, and c corresponds with one of the three loops spoken of
in Fig. 8. There is then in Fig. 6 only one entirely new loop
not indicated in Fig. 6.

The copcum maintains the same position in Fig. 8 as in
Fig. 6. The bend in the large intestine, however, where it
passes into the rectum, shows quite a distinct alteration.
It no longer forms a simi^le acute angle with the rectum,
but is bent in two directions as shown in Fig. 8. This is the
beginning of the formation of a very distinct group of con-
volutions which is perfectly constant and will be descrilu'd
below.

The general tendency in the formation of new loops in
the small intestine is for the tube to become slightly bent on
itself and to grow around an axis which is represented by the
large intestine. The characteristic shape of the loops is
shown iu Fig. 8, d and /. The loops do not meet above (on
the surface towards the head of the embryo); for the large
intestine is situated between the bends of the loops. in such
a way that it could be lifted away from the small intestine
by drawing it towards tlie head, but not by drawing it towards
the tail of the embryo. The arrangement becomes less reg-
ular the nearer it is to the stomach, for the gi-owth in this
rc'gion is more rapid and the pressure exerted on the coils
greater than in other jiarts.

Fig. 9 represents tlie dissection and Fig. 10 the model
of the intestines of a pig 30 mm. long. The general position
of the various parts is much like that in Fig. 8. By following
the letters on Figs. S and 10 the corresponding loops can be
made out. There are yet no groups of coils to be distin-
guished. Tlie small intestine can be roughly compared with
a hollow^ cone whose axis is represented by tlie large intestine.
The loops ;r and ?/ have become more fully developed and
grow around the large intestine in the characteristic fashion.
The loops in the figures arc lettered only on the right side,
since they arc in a certain sense duplicated on the left side
of the large intestine. A loop, however, is a fold which begins
and ends somewhere in the same neighborhood; and it might
be possible to take the median line as the starting point, and
make loops on either side; but it is much simpler to treat as
complete loops only those folds which start on one side and
return to that side.

The large intestine in Fig. 10 holds a straight course from
the ccecuin until it reaches the stomach. It then makes a
complete Ijeiid on itself and enters the rectum as shown in
Fig. 10, g.

Fig. 11 is the dissection of a pig 32 mm. long, and Fig. 12
is a drawing of the model made from its intestinal canal.
A certain general resemblance in outline is seen between
Figs. 10 and 12. The intestine is a cone-shaped mass in
each with the apex extending a short distance into the cord
and the large intestine forming an axis for the cone. The
arrangement of the small intestine in relation to the large
intestine is the same as that spoken of before. The loops

are bent around the axis of the large intestine, especially near
the apex of the cone, i. e. near the cord. At the stomach end
the gut has become so twisted that the individual loops can-
not be traced with any satisfaction. Certain landmarks,
however, can be recognized. For example, the loops .r, y, f
and d correspond fairly well in the two stages, and it is not
difficult to conceive of the transformation of the loop c in
Fig. 10 to the same loop in Fig. 12. This transformation
takes place by a flattening of the loop which will be spoken
of later. It gives rise to a figure which is often seen in the
intestines of pig's embryos.

Although the loops can no longer be individually followed
with ease, there begins at this stage to arise a grouping of
the coils. In Fig. 12 four fairly distinct groups can be made
out. Starting with the stomach end the intestine forms a
mass of loops which are situated mainly on the left side of
the body. In no place does a whole coil of this grouji reach
the surface of the intestinal cone on the right side. Thi.s
will be called group A. After bending in five or six loops,
as represented in the more liglitly shaded part of Fig. 13 near
the stomach, the gut reaches the right side and forms a group
of more or less flattened coils, which form all the surface
coils of the right side up to nearly the beginning of the cord.
This group is shaded darkly in Fig. 12 and ends after the loop
marked d. It includes the coil c described above and will be
designated group C. The intestine leaves this region at the
termination of loop d, and forms three complete loops of the
type described in earlier embryos. These are unshaded in
Fig. 13 and include /, x and //. They form the group />.
These coils are associated more closely than the rest of the
intestine with the cadoni of the c(n'd. At the end of this
group the small intestine takes a straight path for a short
distance and turns on itself in the way seen in all the embryos
so far pictured, and enters the large intestine at the cn?cuiii.
The large intestine is straight as before until it reaches the
region whei'e it turns to form the rectum. Here it is thrown
into irregular twists, as shown in Fig. 13, E. The convolu-
timis formed in this region will be spoken of as the rectal
group or group E, and will be followed through the various
embryos. At this stage it is directly anterior (towards the
head) and lies partly between the groups A and C.

Fig. 13 represents the model of the intestine of an embryo
40 mm. in length. The general outline of the mass of coils
is, as before, cone-shaped. This is accentuated by the in-
creasing complexity of the rectal group, and by the rapidity
of growth of the first ])art of the small intestine. The same
groups described above can be recognized at this stage. The
group .1 has increased consideral)ly in length in Fig. 13 and
can be divided into two groups which are marked .1 and B
in Fig. 13, 11. These become more distinct in later stages.
From B the gut passes over to the right side of the body and
forms the group C which is situated entirely on the right side,
and makes up* most of the surface coils there. This is shaded
in Fig. 13, I. On approaching the cord there are found the
three complete loops described in Fig. 12, as making up
group D. These are almost identical iu the two stages, auu

April-May-Juxe, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

105

extend into the ccrloniie cavity of tlie cord, which has become
gradually more shallow. TIic rectal group is more complex
than in the preceding stages and forms a conspicuous mass
of coils whose calibre is noticealily smaller than in the rest of
the intestine. Its position also has altered. Instead of lying
between groups .1 and (', it is to tlie right of C, having rotated
on an axis corresponding ap]u-oximately with that of the cord.
Figs. 14 and 15 represent the dissection and model resjiec-
tively of the intestine nf an endiryo 4.S nun. in length. At
this stage all the coils are within the main liody-eavity. The

large intestine begins on the right side of group D, a short
distance from its a])ex. The coecum corresponds fairly well
in position with that in Fig. 13. On leaving the eoecum,
liowever, the large intestine passes obliquely down on the
right surface of group C, and is coiled to form the rectal
group, posterior to groups .1 and B. Fig. 14 does not justly
rejtresent the regularity of the looj)s nuiking up group C.
They form a series lying transversely from right to left, and
can be easily separated in a mass from group D on the one
hand, and croups A and B on the other.

smr'

Fin. 18. — A series of diagrams to indicate tlie formation of groups of coils in the intestine. These
represent the intestines of embryos, 13, 21, 2."), 32, 40, 48 and 8.5 mm. in length respectively. The groups are
lettered in correspondence with the preceding ligiires. T/// shows the direction in which the groups have
rotated, their course being marked by curved arrows.

groups described above can be readily recognized, but a con-
siderable change in their position has taken place. The
surface coils near the stomath are derived from group A
instead of group C, as in the stage represented in Fig. 13.
Group A is on the right side of the body, and group B on
the left, (rroup C has moved in a ventral direction and some-
what to the left, until it lies transversely between group D
and groups A and B. Group D enters the main body-cavity
and the regularity of its coils is lost. Instead of being com-
plete and regular, as in Fig. 13, the loops are distorted and
flattened by their association with the other abdominal vis-
cera. The more or less pointed extremity of this group is
still directed towards the cord, as shown in Fig. 14. The

Fig. IG represents the surface coils of the intestine of a
pig's embryo 85 mm. long. Fig. 16, / is drawn from the
ajiimal's right side; Fig. IG, II from its ventral surface; and
Fig. 16, /// from its left side. The various groups of coils
are lettered in correspondence with those pictured in Fig. 17,
which is drawn from a wire model of this intestine. The
surface coils on the right side are formed by groups A and D.
On the ventral surface groups B and C are present; while
the left side is occupied by parts of B and D and the whole
of group E. In this stage the same five main groups, that
have been described, can be made out. It will be noticed,
however, that their relative position is somewhat different.
Group D has rotated posteriorly, dorsally and to the right, so

106

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

that it takes up a position to (he right of, ami posterior to,
group C. It thus moves ]iast group C and earrios the coecuni
with it, so that tlie beginning of the large intestine lies dor-
sally, and posterior to grouj) />. The gr(iu|i E is pushed still
farther in the sauie direction until it is finally situated in the
left dorsal region of the mass of intestines. This group in
the beginning lies on the left anteroventral surface. As it
becomes more coni])lex it moves around to the right initil it
reaches the left dorsal ]iosition. It therefore rotates througii
three-quarters of a circle. The axis of this rotation is a line
drawn from the beginning of the duodenum to a point some-
what posterior to the umbilical cord.

l*"ig. 18 consists of a number of diagrams of the different
stages, showing this rotation of the groups. The straight
dotted line in each diagram represents the junction of the
main body-cavity and the coelom of the cord. Diagram VI
corresponds with Fig. 15, and VII with Fig. 17. The younger
stages can be easily recognized. Diagram VIII shows the
direction in which the groups rotate. The letters in all the
diagrams correspond with those used in the description of
the groups; and in VIII these letters, associated with the
curved arrows, indicate the direction in which those groups
have moved from their original positions.

An appearance which is characteristic of the older embryos
is shown in Fig. 16, /, D and C; and in Fig. 16, II, C. The
regular loops, which have been described, become flattened
by pressure against the abdominal walls, giving rise to the
peculiar coiled appearance represented.

The intestines of several embryos older than those repre-
sented in Figs. 16 and 17 were studied. The groups were
found to correspond with those already described; and an
accoimt of these later embryos would not add any essentials
to the above description. It is possible in these to tell with
considerable accuracy to what group any one surface looj)
belongs.

It will lie noticed that in the older stages, «hich have been
described, the large intestine grows more rapidly than it does
in earlier embryos. In those represented by the first eight
figures there is practically no change in the large intestine.
After this, however, there gradually appears a consideralde
mass of coils to form the rectal group. The part of the small
intestine which is at first present in the cord grows more
rapidly after its return to the general body-cavity. For this
reason as well as on account of the pressiire exerted by the
other viscera, the cone-shaped mass of intestines becomes more
or less spherical after it is entirely intra-abdominal. The
growth, which in earlier stages was almost solely in the
region of group .4, is in the older embryos more uniform
throughout the gut. The younger the embryo, the more
noticeable is this rapid growth in the region of group /i.
This fact was observed by Dr. Mall and indicated in his paper
by means of tables of measurements. In connection with
this it is of interest to note an observation made by Berry,"
who found that the villi appear first in the upper part of the

« Berry, J. M. ; Anatomisclier Anzeijier, xvii Bd., S. 242, 1900.

intestine. Whether or not the number of villi increases more
rapidly in this region than hnver down, has not been deter-
mined.

In reviewing a considerable numlier of embryos in this
way and modeling their intestines Ijy a method in which errois
can be easily controlled, one cannot help being struck by the
remarkable constancy of the appearances met with. At first
glance it is more noticeable in the earlier embryos. This
fact is due to the greater simplicity of the loo]is and to the
smaller chance f(u- distortion of the coils by pressure. It will
be noticed that there is practically no variation in the portion
of the intestine contained within the cord. In that part of
the body-cavity there are no other viscera to interfere by
])ressurc with the growth. If it were possible to isolate an
organ during its development, its form would undoubtedly
be difTereut from what it is when it develops a contact with
many other growing organs. The portion of the intestiiie
which develo])S in the ccu'd is to a certain extent isolated. The
j'npidly-growing viseeia, such as the liver and urinary organs,
can in no way intcrfci'e with lis growth; and it is seen from
the above descriptions that it is this part of the intestine in
particular, which is entirely constant in its appearance. Here
the intestine increases in length by the formation of regular
loops which grow up and surround the large intestine, as
already stated. At first sight it woidd appear that this man-
ner of growth might be caused by the confinement of the
intestine in the cylindrical cavity of the cord; but the same
method of formation of loops takes place in the general liody-
cavity before any loops whatever appear in the intestine of
the cord. Since it thus takes jilace in two parts of the intes-
tine under difl'erent conditions, it is fair to assume that this
is the natural tendency in the growth of loops in the intes-
tine of the pig.

Dr. Mall, in the publication already referred to, has dis-
cussed the entry of the intestinal loojis into the ccclom of the
cord, and their return to the general body-cavity. He in-
clines to the belief that the gut is forced into the cord liy the
pressure exerted on it by the other rapidly-growing viscera;
and that it returns to the main body-cavity on account of a
twisting of the loops already contained in tlie abdomen. The
dissections of the pig's embryos, which have been described,
throw no new light on this subject. The ca?lom of the cord
in early pig's embryos is of considerable size and the intestine
is at first only a single loop. Hence it is not hard to imagine
its being pushed into this easily available space in the cord.
Here it remains until the secondary loops are formed, which
make up group D. This group is more or less cone-sha]ied
and fits into the cavity of the cord which has a similar form.
The passing of this group to tlie main body-cavity does not
take place one loop at a time. The group returns ajiparently
by a gradual obliteration of the cone-shaped cavity of the
cord fi'oni its apex to its base.

It can hardly be said that the coils enter the abdominal
cavity from the cord in any regular order. The order of their
entry is dependent on their position in the mass of coils which
projects into the cord. The apex of this mass is formed by

April-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

107

the lower end of the ileum where it turns on itself to join
the large intestine. The apex leaves the cord last, and hence
the lower end of the ileum is the last part to enter the ahdomi-
nal cavity. In the same way the coecum enters a short dis-
tance in front of this part of the ileum, simply because it is
so situated in the group of coils.

In connection with the development of the mammalian
intestine. I wish to call attention very briefly to the intes-
tines of the various lower vertebrates. In Amphioxus the
alimentary canal consists of a simple straight tube with no
convolutions whatever (Fig. 19, A). In the shark the intes-
tine is straight, but the stomach is bent on itself so as to
form a descending, and an ascending part (Fig. 19, B). In
the jierch, as in most Teleosteans, there is one distinct loop in

Fio. 19. — Diagrams reiireseuting the intestines of -■!, Ampliinxus; B,
Sliarl< ; C, Percli ; I), Frog; E, Turtle; F, Sparrow.

tlie intestine, as shown in Fig. 19, C. There are two methods
in these animals l)y which the digestive surface is increased in
extent, namely, by the so-called spiral v.-dve and by the
pyloric coeca. The spiral valve consists of a longitudinal fold
extending into the cavity of the intestine. It is present in
all Klasjnobranchs, Dipnoi and Ganoidei, hut not usually in
the Teleostei. The pyloric cceea may be very numerous and
form a large mass of processes just below the stomach. The
spiral valve and the pyloric cceea are seldom both highly
develo])ed in the same animal.

In the Amphibia the intestine is, as a rule, much more
conijilex than in the fishes. As shown in I''ig. 19, D, the
frog's intestine is considerably coiled. In a ninn1)er of frogs
anil toads which were dissected, tlie intestines were found to
be ai-ranged according to a general type which is I'cpicscntcil

in Fig. 19, D. In some cases, however, the coils assumed a
much more complicated mass than that shown in the figure.
It is interesting to note here that in some stages of the tad-
pole's life the intestine is a much more complex organ than
in the adult frog. The intestine of Necturus shows a coiling
which is usually not so great as in the frog.

In the Eei)tilia the form of the alimentary canal is consider-
ably modified by the shape of the body. In Fig. 19, E, is
represented the stomach and intestine of a turtle. This is an
arrangement which was found to be very constant. In snakes
the coils are not so numerous and are somewhat obliterated
by the narrowness of the body. In lizards the intestine is
coiled more than in either the turtle or the snake. Thus it is
seen that in reptiles, and amphibians there is a much more
complex arrangement of the coils of intestines than in fishes.

In birds there is a still greater complexity in the form of
the intestine. Birds of the same species show very little
variation in the arrangement of the coils. In a number of
sparrows, robins and blackbirds the arrangement was found
to be according to a type represented in Fig. 19, F. There
was very little divergence from this type in any of the speci-
mens examined. In the chicken, however, there is a far
greater coiling. In several chickens examined there was
found a noticeable constancy in the arrangement of the loops.
A long duodenal fold extends from the gizzard backward and
to the left side of the body. Turning on itself it passes to
the right side of the body, where the small intestine is thrown
into a number of coils which resolve themselves into two
main groups. From the rectum two long coeca extend for-
ward.

In the study of these few lower vertebrates two main points
are to be observed: (1) the constancy in the arrangement of
the loops in nearly related animals; and (2) the gradual in-
crease in complexity of the coils as we pass from the lowest
vertebrates to those higher up in the scale. It is interesting
to note also a certain relation which seems to exist between
the ontogeny of the intestinal canal in mammals, and its
phylogeny. Beginning with a straight tube in the early
mammalian embryo the intestine is thrown into a gradually
increasing number of loops. Beginning in the same way with
Amphioxus we may jiass from the fishes, which possess but a
single loop, to the amphibians, whose intestine is much more
complex; and fiom these to the birds and mammals, where
the alimentary canal is a very much coiled organ.

Recapitulation.

The intestine of a pig's embryo at an early stage consists
of an uncoiled tube which sends a single loop out into the
ccelom of the cord. The first half of the loop is on the right
side and gives rise to the small intestine. From the other
half is formed the large intestine. The gut increases in
length by the formation of regular loops which grow around
an axis corresponding with that of the cord and the large
intestine. 'I'hese loops form first in the part which is to
become the small intestine. They also develoj) in that part
of the small inlesliiie near the stomach before they a]ipear in

108

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

the cord. Up to a certain stage the further growth in com-
plexity is greatest near the stomach. After tlie small intes-
tine has become considerably coiled, a mass of loops is formed
in the large intestine. In embryos between 3.5 mm. and -10
mm. in length the group of coils which has formed in the
ccelom of the cord, enters the general body-cavity by a mech-
anism which is not clearly understood. In embryos of the
same size the coils are constant in arrangement and definite
in their position. Tliey can be followed through various
stages of the early development. In older embryos, when
tlie individual coils cannot be recognized with ease, they are
found to be arranged in distinct groups which have definite
situations in the body-cavity. The loops in a certain region
of the body-cavity, tliongh they may vary in form, always
belong to the same group. These groups arrive at their final
situation by a rotation which takes place posteriorly and to
the right around an axis, running from the beginning of the
duodenum to a point a short distance posterior to the opening
of the cord. It is not at all claimed that the surface coils
hold always the same position with regard to one another, or
that the coils always have the same relation to one another
in the group; but it is to be emphasized that the groups always
do hold the same relative position in the body.

In lower vertelirates the intestine increases in complexity
as we ascend the scale. The intestinal coils are very similar
in nearly related animals; and a certain amount of constancy
is noticed in their arrangement.

I regret that I have had no opportunity of confirming
Dexter's work on the cat's intestine, in which he finds no
constancy in the position of the loops. However, from the
researches, already referred to, of Henke, Weinberg, ilall and
Merkel, as well as from the present study of pig's embryos
and the intestines of lower vertebrates, it seems plain that
the intestinal canal is an organ which is situated in the body
in a definite position, and that its different parts hold a con-
stant relation to one another.

DESCKII'TKIN OF PLATES .XIX-XX.

Fio. 1 Pig's embryo 13 mm. long, showing a single loop of iiitustiu

extending into the umbilical cord.

Fig. 3. — Pig's embryo IS mm. long, showing a loop of intestine iu
the cord with a distinct ccecum. The small intestine shows the begin-
ing of coils inside the main body-cavity. The dotted line indicates the
original outlines of the body before the removal of the liver.

Fig. 3. — Pig's embryo 31 mm. long, showing a slightly more convoluted
small intestine. The numbers 1, 3 and '•> correspond with those on
Fig. 3.

Fig. 4. — .1. Dissection of pig's embryo 33 mm. in length.
B. Wire model of the intestine of this embryo.

Fig. .'i. — Wire model of intestine of pig's embryo 3.5 mm. long. The
lettering corresponds with that iu Fig. 4, B.

Fig. C Wire model of intestine of pig's embryo 3.5 mm. long.

Fig. 7. — Dissection of pig's embryo 38 ram. long.

Fig. S. — Wire model of intestine of the embryo represented in Fig. T.

Fig. 9. — Dissection of a pig's embryo 30 mm. long.

Fig. 10. — Wire model of intestine of embryo represented iu Fig. 9.

Fig. 11. — Dissection of a pig's embryo 33 mm. long. C, superficial
group of coils on right side of body. The small letters correspond with
those used above.

Fig. 13. — Wire model made from the intestines of the embryo repre-
sented in Fig. 11. .4, C, D and E, iudicate the formation of groups of
coils. The group C is shaded.

Fig. 13. — Wire model of intestine of an embryo 40 mm. iu length.
The groups are lettered as in Fig. 13.

Fig. 14. — Dissection of a pig's embryo 48 mm. long. The letters as
before iudicate the groups of coils.

Fig. 15. — Wire model of intestines of embryo represented in Fig. 14.
Groups are indicated by shading.

Fig. 16. — Dissection of a pig's embryo 85) mm. long, /shows the
intestines from the right side; //from the ventral surf.ace; and///
from the left side. The lettering corresponds with that in the previous
figures.

Fig. 17. — Wire model of intcstiue of embryo represented iu Fig. Ifl.

Note: — No attempt has been made to retain the relative size of the
embryos iu these figures. The actual measurements are giveu iu each
case.

BILATERAL RELATIONS OF THE CEREBRAL CORTEX.

By E. Lindon Mellus, M. D.

(From the Aiititotnirnl Ltfbvratonj, Jn/nm Ifttpkhix I'/tift'rxlty.)

In the study of the central nervous system it becomes
more and more apparent that the statement that each cerebral
hemisphere controls the opposite half of the body must be
still further modified. It has long been recognized that cer-
tain movements were more or less bilateral; that is, equally
controlled by each hemisphere. This is easily demonstrated
by electrical stimulation of the cortex and, to a certain extent,
the anatomical relations have been worked out. The bilateral
representation of most facial movements would appear at
first thought to be quite essential and anatomists held, long
l)efore it was demonstrated, that each of the motor nuclei
in the pons and medulla was connected with its fellow of the
oiiposite side by decussating filires. Bilateral movement

could thus be accounted for by simultaneous stimulation of
the nuclei of both sides, but the results of some of the more
recent investigations show that projection fibres run directly
from the cortex of each hemisphere to the nuclei of both
sides. This provides for simultaneous stimulation, while the
fibres passing directly from one nucleus to the other may
conserve the symmetrical discharge of energy.

The necessity for bilateral control of the limbs is not so
evident, but the fibres of the so-called direct or uncrossed
pyramidal tract in man and the finding of bilateral degener-
ation in the cord after unilateral lesion of the brain seemed
to make it probable. For some time it was not possible to
trace tlie cdurse of this homolateral deoeneration from the

THE JOHNS HOPKINS HOSPITAL BULLETIN. APRIL-MAY-JUNE, 1901.

PLATE ^IX.

Fig. 11,

MacCallum del.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XX.

Fig. 12.

Fig. 14.

Fig. 1:J.

Fig. 15.

MacCallum del.

Fig. 17.

Fig. 16.

Apkil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

109

brain to the cord, and various theories were brought forward
to explain it. It was considered probable by some anato-
mists that the pyramidal tract divided at the decussation,
some fibres passing to the lateral column of each side, while
a portion remained in the anterior column as the direct
tract; but in the absence of confirmation Sherrington's theory
of " recrossed " fibres was generally accepted. Sherrington's
conclusions were based upon experimental unilateral lesions
on the brain of the monkey, in which he claimed that im-
mediately below the decussation the degeneration was all on
the opposite side of the cord, while at a still lower level
degenerated fibres were fomid in botii lateral columns. He
thereupon assumed that all the degeneration crossed over in
the decussation to the oj)posite side of the cord, but a portion
crossed back at a lower level to the lateral column of the
same side. The probable explanation of his mistake is that
at the time of his observations the delicate methods in use
in recent years were not known. Still the fact that he
reported at the same time that fibres from the upper limb
area of the cortex passed down the entire length of the cord,
while fibres from the leg areas disappeared from the cord
in the cervical and upper dorsal regions, would indicate that
his preparations were handled or studied somewhat carelessly.
It is rather curious that no one seems to have suggested that
he had mixed up those cords.

Soon after the publication of Marchi's method of staining
degenerated nervous tissue by osmie acid, Muratow undertool'
the study, by that method, of degenerations following lesions
of the brain in the dog. He published the results of his
observations in 1893 ' and clearly showed that in the dog the
]iyramidal tract divided at the decussation and a portion
]iassed directly to the lateral column of the same side. I had
been working with the same method tracing degenerations in
the central nervous system of the monkey after very minute
lesions of the cerebral cortex, and at the time of the appear-
ance of Muratow's publication I had already accomplished
the same results on the monkey, but to him undoubtedly
belongs the credit of priority. These results have since been
confirmed by other investigators, and Dejerine and Thomas "
and Eisien Eussell' have proved the existence of the same
conditions in man.

At the same time I was able to demonstrate the passage of
fibres from the pyramid of one side directly to the motor
nuclei of both sides in the pons and medulla.'

The following experiment enlarges still further the scope
of bilateral representation and adds another to those paths
already demonstrated l)y wliich one hemisphere may control
more or less both halves of the body. It by no means stands
alone, but is presented as the type of a considerable group
which will be considered individually in a later publication.

On September 20, 1898, I operated in ]\Ir. Victor ITors

■ ArchtT fur Anatomic und Entwickelungsgescbkbte. 1893.
5 Dejerine and Thomas. Archives, de pliysiol. norm, et patholog. 18%,
No. 3. Review in Neurologisehes Centralblatt, 1897, p. 503.
sRisien Russell. Brain. Summer, 1898.
' Proo. Roy. Soc. vol. .58.

ley's laboratory at University College, London, on a small
but apparently healthy bonnet monkey (Macacus sinicus).
The animal being etherized, the cortex of the left hemisphere
was exposed under strict aseptic precautions, the centre for
thumb movements determined by electrical stimulation and
that portion of the cortex carefully excised. Care was taken
not so much to remove every portion of cortical substance as
to avoid injury to the underlying white matter. I therefore
passed the knife under the cortex with the flat surface of the
knife parallel to the convexity of the hemisphere, bringing
it out at a right angle to the line of incision. Then lifting
the cut edge with a pair of small forceps the excision was
easily completed. The slight hemorrhage was controlled
with hot saline solution, the wound closed with horsehair
sutures and dressed with borated cotton smeared with collo-
dion. This monkey got dian-hoea and died on the tenth
day after the operation (September 30) of marasmus. The
wound in the scalp had healed well and there was no trace of
sepsis. The brain and cord were removed, kept for four
days in formalin and then transferred to Miiller. The brain
was cut into thin segments in a plane nearly parallel to Lhe
occipital sulcus (Aft'enspalte), as shown in Figs. 1 and 3, and
stained by the Marehi method. It was my endeavor to make
the plane of section correspond as nearly as possible to the
course of the projection fibres through the internal capsule.

Description of the Lesion*.

Tlie portion of cortex removed was circular and about one
cm. in diameter. About one-third of the area of the lesion
was in the ascending parietal convolution and the other two-
thirds in the ascending frontal. Its posterior extremity was
about midway between the lowest portion of the interparietal
sulcus and the fissure of Rolando, while its anterior boundary
was the superior angle of the sulcus precentralis. The lowest
portion of the lesion was very nearly opposite the lower
extremity of the interparietal sulcus, and it extended upward
to the superior frontal sulcus.'* The lesion in the ascending
frontal was much more shallow than in the ascending parietal
and the entire cortical substance was removed only at that
portion of the ascending parietal convolution nearest the
centre of the lesion, close to the fissure of Rolando. It was
at this point that uncomplicated flexion of the thumb was
obtained on stimulation with a weak faradic current. The
portion of cortex removed became thinner from the centre"
to the periphery of the lesion. In the hardened brain there'
was evidence of slight cerebral hernia, i. e. bulging of the
brain into the opening in the skull, which accounts for the
irregularity of contour in Fig. 3.

In Figs. 1 and 3 I have eiuleavored to show the distribu-
tion of association fibres to the external surface of the two
hemispheres, the proximity of the oblique parallel lines to
each other corresponding to the amount of degeneration
found in the various convolutions. It was impossible to

■>» In Fig. 1 the lesion does not extend upward as far as it should. It
is better represented in Fig. 3.

110

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

represent the comparative amount of degeneration so accur-
ately in the outline drawings of transverse sections of the
brain (Figs. 3 to 7 inclusive), because in so small a figure,
in order to have the degeneration show at all, it was necessary
to exaggerate. Degenerated fibres can be seen crossing in
the corpus callosnm in all the segments except " E," the
most posterior. The distribution of association fibres to the
convolutions of the two hemispheres is very nearly equal and
quite sj'mmetrical. It extends also upon the internal (mesial)

Fig. 1.

surface of both hemispheres as far as the calloso-marginal
fissure.

In two segments, C and D, the degeneration extends to the
superior temporal convolution of licith sides. The route
taken by the degenerated fibres to reach the temporal lobe
is the same in botli hemispheres and is interesting. In sec-
tion " B " (Fig. 4) a few degenerated fibres appear among the
fibres passing to the superior temporal convolution just ex-
ternal to the thickened lower edge of the claustrum on both

Fig. 2.

sides. In the segment posterior to this (Fig. 5) many degen-
erated fibres can be seen leaving the internal capsule, break-
ing through the thin inferior edge of the lenticular nucleus
and passing below the claustrum to reach the superior tem-
poral convolution. Some of these fibres probably terminate
in the lateral geniculate body. Although no continuous
fibres could be traced from the internal capsule into the
lateral geniculate body, it lies directly in the path of those
running to the lemporal lolie and there is considerable degen-

eration in this nucleus in both liemispheres. Still posterior
to this (Fig. 6) degenerated fibres are passing between the
islets of gray matter representing the prolongations of the
putamen, while many others may be seen passing down
among the fibres of the external capsule. The degenerated
fibres in the superior temporal convolution are apparently
continuous with both these tracts, the course of which is the
same in both hemispheres.

Taking into consideration the movements represented in

Fig. 3.

that portion of the cortex removed, the distribution of asso-
ciation fibres is of especial interest. While the centre for
uncomplicated movement of the thumb occupies but a small
portion of the area removed, movements of the thumb as part
of some associated movement or march may be obtained not
only from every portion of that area but also from points
considerably removed therefrom — even as far down the con-
vexity of the brain as the lower extremity of the fissure of
Rolando. It is a question of much interest whether this is

Fig. 4.

Ijrought about by means of association fibres or projection
fibres passing directly from each of tlie widely separated cor-
tical areas to the system of secondary neurons in the cervical
region of the cord. It is quite possible that complicated
movements may be brought about in either or both ways.
The great increase in cortical association tracts between mon-
key and man suggests the possibility of inconceivable degrees
of association.

Looking upon the motor cortex as representing the centres

April-Mat-Juxe, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Ill

for associated movements one would naturally expect to find
projection fibres passing directly down through the capsule
from that part of the cortex, giving rise to the movement.
As I understand the significance of excitation experiments
upon the cortex, the finding of a <?entre for the imcompli-
cated movement of the thumb only means that in the move-
ment represented at that spot, the movement of the thumb
(flexion or otherwise) is the first or initial movement of the
march. If the stimulation is continued or increased the

Fig. 5.

march is continued or completed unless interrupted by a
.general convulsion. Thus, if the anaesthesia is at just the
right stage the gentlest stimulus only excites the first or
initiatory movement of the march. In opposition to such a
theory it may be urged that only one centre has been found
in any single animal for such uncomplicated or initial move-
ment, while many combinations are possible beginning with
such movement. This woiild hardly render an entirely sepa-
rate centre for each movement necessary, as they might ali
be grouped about the common centre.

Fig. li.

In experimental destruction of small cortical areas in tlio
monkey I have often traced projection filires into the cervicil
region of the cord from portions of the facial area far re-
moved from arm centres. Such fibres probably represent the
conduction paths for impulses, giving rise to movi'ments in
which the arm is associated with facial movement. Such
movements or actions are numerous in the monkey and in-
crease as we go u]) in the scale. For example, in feeding,
the monkey stretches out his arm, opens the hand Id lay hold

of the object, which he grasps and carries toward his already
opening mouth. In this instance the extension of the arm
is the initial movement, followed by extension of the thumb
and fingers, then flexion, etc. Such a movement or marcli
is 'of course much more complicated than any movement
obtained by electrical stimulation of the cortex. But it must
be assumed that the normal discharge of energy from the cells
concerned in the cortical reflex, as a result of incoming sensa-
tions, is a very different affair from our experimental stimu-
lation. Stimulation of the motor cortex with a weak faradic
current gives rise to certain movements. Cut away the cor-
tical cells and stimulate the cut ends of the projection fibres
immediately beneath and you get the same result. Who can
say these results are or are not brought about in the same
way? Does the former experiment induce a discharge of
energy from the cell or does the current passing through the
cell to the axis cylinder act exactly as in the other instance?
However this may be we cannot safely assume that stimula-
tion experiments disclose more than a hint of the functional
activity of the cortex.

A study of the excitation experiments of Beevor and Hors-
ley° on the bonnet monkey shows that they obtained from

the cortical area corresponding to the lesion in this experi-
ment:

Movements of thumb of the opposite side: flexion, exten-
sion and adduction:

Flexion and extension of the fingers, opposite side;

Movements of wrist, elbow and shoulder, opposite side;

( 'losure of opposite eyelids;

Turning of the head to the opposite side;

Retraction and elevation of the corner of the moutli, opiio-
site side;

Pouting, pursing and rolling in of the lips, more of the
opposite side, but often bilateral;

Ojieuing of both eyes and

Eetraction of the head.

The last two were each observed only once in fifteen ex|)eri-
ments. These movements were obtained from various points
within the given area but in no single animal were they all
observed, nor was any one of these movements obtained from
exactly the same point in all the animals experimented upon.
Most were primary, though sometimes secondary or tertiary.

■Beevor ami Ilcirsley, Phil. Trans. Royal Society, B. 1887 ami 1S94.

112

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nus. 131-122-123.

No purely piimaiT movcincnt was ol)t:i'r\(.'i1 (iT tlio elliow or
tlio fintjcrs.

On stiimilation of the cortex of tlie orang outaiig the same
investigators ° observed opening of the eyes and turning the
head and eyes to the opposite side represented in the same
area, or ratlier in that part of it anterior to tlie fissure of
Rolando. This march, it will be seen, is also represented
within this area in the Bonnet, though not so clearly brought
out as in the latter. It is of especial interest in connection
with the considerable degree of degeneration found, in the
experiment here described, in the superior temporal convolu-
tion, now well established as the auditory centre. The asso-
ciation of this cenlre with that jiortion of the cortical area
which controls the opening of the eyes followed by syn-
chronous movement of the head and eyes would seem to be
the anatomical basis of a cortical reflex of primary import-
ance to self-preservation in all wild animals. It is also to
be noted that the distribution of these fibres is quite bilateral.
The fact that in this ease they degenerate toward the auditory
centre, instead of from it, may be urged against the supposi-
tion that these fibres are a link in this reflex, but the anatom-
ical relations of the two centres are certainly intimate and
direct.

The feature of special interest in this group of experiments
is the large nundier of degenerate fibres passing from the
area of the cortical lesion over the middle line in the corpus
callosum and down the internal capsule of the opposite side.'
With the exception of those fibres going to tlie superior tem-
]ioral convolution of the opposite side, tlu\se fil)res, in this
ex]ierimont, all pass into the thalamus. In a few animals,
in which practically the same area was extirpated, some of
the degenerated fibres found in the internal capsule of the
opposite side can be followed through the ])ons and medulla
into the eei'vical region of the cord where they disapj)ear.

Nerve fibres within the central nervous system usually
functionate in the direction of degeneration, but there is
nothing in the character of the degeneration to suggest the
character of the function. This can only be guessed at by
the origin, course and termination of the fibres and what

«Beevor and Horsley, Phil. Trans. Royal Society, B. 1890.

' The writer lias found the same thing — degeneration in the internal
capsule of both sides after unilateral lesion in the brain, in the dog. In
the dog all the degenenatiou in the internal capsule of the opposite side
ends in the thalamus.

we know of tlie function of the areas and structures thus
anatomically associated. Some of the projection fibres pass-
ing inward from the motor cortex clearly carry motor im-
pulses, but it cannot be assumed that all do. A vast number
of projection fibres arising in the motor cortex end in the
thalamus; I think I may say in the thalamus of both sides.
A careful study of the brains of a large number of animals,
mostly monkeys, the subjects of experimental lesions of the
cortex, leads me to conclude that this anatomical connection
of each thalamus with the cortex of both hemispheres is most
evident in those instances in which the area excised was that
in wliich movements more or less bilateral are represented.
These movements are mostly facial; such as are calleil into
play in the expression of the emotions. May not this have
some bearing on the fuiution of the thalamus? It has been
suggested that the thalamus is the centre for reflex or emo-
tional movements.' In unilateral facial palsy the escape of
the emotional paths has long been a puzzle. According to
present conceptions the cortex is concerned in all reflexes in-
volving consciousness. Many cortical refle.xes are purely vol-
untary. The part played by volition in those cortical reflexes
termed emotional, such as the play of the features in facial
expression, is open to discussion, but it can hardly be doubted
that they are as much cortical reflexes as any of the so-called
voluntary movements. The interposition of the thalamus
in such an arc and the anatomical connection of each hemis-
phere with both thalami, as here demonstrated, may explain
the play of the features as the result of emotion when vol-
untary movement is impossible. In many extensive lesions
of the internal capsule fibres passing into the thalamus, even
on the side of the lesion, might easily escape injury, even if
bilateral control of the thalami were improbable.

As to the functions, other than motor, of projection fibres
from the motor cortex, it is at least possible that some serve
the purposes of inhibition, voluntary or otherwise. It seems
altogether reasonable that voluntary inhibition of certain
visual reflexes might be essential to holding the eyes fixed
upon a given object. This is suggested as a possible explana-
tion of the presence of degenerated fibres in the lateral genicu-
late bodies in this case (Figs. 5 and 6). There is certainly
no reason why the reflex might not be inhibited in the genicu-
late body before it reaches the motor oculi nuclei.

8 Bechterew. Leitungsbalmeu im Gehiru uud Riiolienmark. Zweite
A ullage.

A NEW CARBON-DIOXIDE FREEZING MICROTOME.

liv ClI.VRLES EUSSELL BaEDEEN, M. D.,

Assnciale in Anatoiiii/, The Johns Hopl-ins Universili/. Bnlliiiiore.

The carbon-dioxide freezing microtomes in common use
in pathological laboratories have several drawbacks. Of these
the most serious are those due to the use of a rubber tube to
connect the tank with the freezing stage. In addition to the

annoyances due to the rubber tube the microtomes are so
constructed as to utilize but a slight fraction of the heat
absorption due to the expansion of the liquid earlKm-iliiixido.
Ill order to oliviale these drawbacks the microtome described

April-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

113

below was devised. In the designing of the original machine
I had tJie assistance of Mr. E. F. Xorthrup. In the construc-
tion of the present machine I am indebted to Bausch and
Lomb, who manufacture it, for several modifications which
have simplified tlie instrument and rendered it more useful.
Figure 1 shows the machine as it stands ready for use. It
is made to screw directly npon the nozzle of the carbon-
dioxide tank. The valve of the latter is utilized to control
tlie escape of the gas into the freezing stage. When the
microtome is screwed directly upon the carbon-dioxide tank
it is necessary that the tank should lie in a horizontal posi-
tion, on a table for instance, where it may be held in place
by some simple clamp. On the other hand, if it is desired to
connect the microtome to a tank placed in some other than
the horizontal ]iosition an L-'shaped piece of tubing may be
screwed on the nozzle of the tank and the microtome on the
other end of the L tube. The tank may then be placed in
any position desired.

Fig. 1.

A. Cover of freezing stage.

B. Glass track for carrying kuife.

E. Spiral spring.

F. Tubal base of knife-stage.
1. Wheel.

J. Nut for attachiug axial tube to tank.
M. Handle of tank-valve.
N. Pointer.

The axis and main support of the machine consists of a
solid tube with a narrow himen {K-D, Fig. 2). This axial
tube is united by a nut (.7, Fig. 1 and Fig. 2) either to tlie
nozzle of the tank or to the L-shaped tube mcntidiu'd above.

The machine is thus very readily attached.

On the top of the axial tube the freezing stage (.1, Fig. 1,
A-C, Fig. 2) is screwed. This stage piece consists of two
parts, a base and a cover. The base is the part screwed into
the upper end of the axial tube (C, Fig. 2). To this base
the cover-piece is .screwed (.1. Fig. 2). Between the base of
the stage and the axial tube is placed a thin brass plate

(D, Fig. 2) with a very narrow aj)erture at its centre.
Through this narrow aperture the carbon-dioxide escapes
into the lumen of the stage piece (C, Fig. .2). The difference
in pressure on the two sides of the brass plate causes a very
rapid expansion of gas between the cover and base of the
freezing stage. The passage open for the escape of gas from
the lumen of the base {C, Fig. 2) to the external world is in
the form of a s])iral passage which finally opens out through
the side of the cover, as shown in (Fig. 1, .1). Between tlie
cover and base of the freezing stage an asljestus washer is
]i]aced. The exjianding gas therefore can absorb little heat
from the base of the stage. Almost all heat absor]ition must
take place from the cover. This heat absorption is greatly
facilitated by the metallic spiral which projects down from
the cover so as to give rise to the spiral passage through
which the gas escajies.

Througli the mechanism here descrilicd far the greater part
of the heat-absorbing power of the expanding gas is utilized

A B

G l^

A.
B.
C.
D.
E.
F.
<i.
H.
I.
J.
K.

Fig. 3.

Cover of freezing stage.

Glass track for carrying-knife.

Aperture in base of freezing stage.

Aperture in thin brass plate.

Spiral spring.

Tubal base of knife stage.

Check for limiting movements of knife-stage.

Groove for G.

Wheel.

Nut for attaching axial tube to tank.

Opening into lumen of axial tube.

to lower the temperature of the surface of the cover of the
freezing stage. The temperature of the rest of the machine
is but little altered. Good control of the temperature of the
freezing stage can be thus maintained. This control is far-
ther rendered possible by the valve of the tank. If this valve
is turned on full the temperature of tlie cover nf the freezing
stage is quickly reduced to a very low point. Tissue placed

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

on it is quickly frozen. On the other hand, if the gas is not
allowed to escajie from the tank with full force the difference
in pressure in the two sides of the brass plate is less and heat
absorption from the cover is less marked. In this way tissues
placed on the cover may be slowly frozen without suljjecting
them to severe cold. Thus, too, a constant low temperature
may be maintained by opening the tank-valve to the required
point.

The mechanism for controlling the thickness of the sections
is equally simple. On the lower end of the axial tube a
movable wheel {I, Fig. 1 and Fig. 2) is placed. This wheel
moves up and down the axial tube on a screw thread cut
twenty-five threads to the inch. A complete revolution of
the wheel therefore raises or lowers it a millimeter. The
margin of the wheel is divided into fifty spaces, each of
which therefore represents twenty microns. A pointer (iV.
Fig. 1) serves to indicate the number of spaces passed in a
partial revolution of the wheel and thus to show the thickness
of the sections cut.

The knife-stage {F-B, Fig. 1 and Fig. 2) consists of a tubal

base (F). whii-li surrounds the axial tube and rests on the
mova1)le wheel; and of two flanges {B) which extend above
the freezing stage on each side for the support of the cutting
blade. The base of the knife-stage is moved up the axial
tube by screwing the wheel ujiwards. It is forced down the
axial tube by the spring (E, Fig. 1 and Fig. 2) whenever the
wheel is turned so as to be carried downwards. Tlie flanges
of the knife-stage support parallel glass tracks upon which
the cutting blade is carried to and fro.

For cutting sections a razor or a plane or almost any good
steel blade with a straight edge may be used.

The advantages of the machine are as follows:

1. But little carbon-dioxide is wasted.

2. The temperature of the freezing stage can be controlled.

3. Owing to the nature of its attachment to the tank it can
be readily carried about. This should render it of especial
value to surgeons.

4. Above all it is simple in design, strong, and unlikely to
get out of order.

NOTES ON CERVICAL RIBS.

(Froii) the Aniitninii'id Luhoratorij

Altliough nianv cervical ribs have been described hereto-

fore, the following description of three cases is given because
of variations presented which, while most of them have
already been recorded, are somewhat rare.

(Jase I. Fig. 1. The dissection of this subject was nearly
completed before the cervical rib was noticed, so that most
of the soft parts had already been removed before it came to
my hands.

There was a cervical rib on each side, the left being much
better developed tl-an the right. Each rib was made up of
head, neck, tubercle and shaft. Each articulated with the
seventh cervical vertebra on the body and on the transverse
process. There was a simple stellate ligament at the costo-
central articulation, and a capsular ligament at the articula-
tion of tlie tubercle with the transverse process.

The left rib extended down to the upper liorder of the
first thoracic rib, witli which it articulated, lieing held in
position by a capsular ligament. There was a slight articular
eminence or facet on the first thoracic rib at the point of
articulation, the facet apparently corresponding to the scalene
tubercle of a normal first thoracic rib. The left cervical v\h
projected a distance of 2.3 cm. beyond the body of the
seventh cervical vertebra and then curved sharply downwards.
The extreme width of the rib was at this point, where it
measured !.(! cm. The shaft of the rib was triangular in
cross-section and measured .4 cm. in thickness.

The sevcntli cervical nerve on the left side crossed the
middle cif tlu' livoad up]ier half of the rili in a well marked
groove.

By Clinton E. Brush, Jr.

of file Jiihiis Iliipktns Unlfersili/.)

At a point 2.G cm. from the distal end of the rib was the
superior border of a sharply defined groove, .9 cm. in width.
Across this jiassed the lower trunk of the brachial plexus (1),
the eighth cervical and first thoracic nerves uniting before
crossing the rib. As the truid'; of the brachial plexus was

YlG. 1.

C.^SE I. — 1. Lower cord of brachial plexus. 3. Sui)pleineiitar_v iuter-
eostal uerve. 3. Fibrous cord.

but .4 cm. in diameter, it is probable that the subclavian
artery also crossed iu this groove.

In the supplementary interspace there were some well de-
veloped muscle fibres, but their condition was such that it
was impossible to decide wliether or not tliere had been both
an inner and an outer set. ,lust before crossing the upper
border of the first tiuu'acic rib, the eightli cervical nerve

Ai'iai.-MAY-JrM-;, lOdl.]

JOHNS PIOPKINS HOSPITAL BULLETIN.

115

<iave off a small branch (2), which divided into several smaller
twigs to innervate the supplementary intercostal muscle.

The right cervical rib corresponded very closely in size and
shape to the upper half of the left rib. It extended 1.7 cm.
beyond the body of the seventh cervical vertolira and was 1.4
cm. wide. The upper border curved sharply downwards and
met the lower border 2.6 cm. below tlip tuliercle. so that the
rib ended in a point. From this pointed end a round, lihrous
cord (3) extended to the first thoracic ril). meetiui;- it al a
point corresponding to the place of articulation of tlie left
cervical i-ib with the first thoracic rib (ui tlie left side.
l'"r(ini bere the fibrous cord was continued along tlie superidr
liin-ilcr of the first thoracic rib to the stcrntnn.

On the riglit side also the supplementary inlers|iace C(in-
tained well developed muscle filires, the nerve suiiply lieing
similar to that on the left side.

'I'he distribution of the arteries that were still on the
subject was normal, except that nn buth sides the verteljial
arteries passed up to enter the foramina of the transverse
processes of the fifth cervical vertebra.

Fig. 3.

Case II. 1. Groove for subclavian artery and lower cord of brachial

plexus. 3. Groove for VII cervical uervc. 3. Ligament. 4. Capsular
liijauient. 5, (I, 7 and 8. Liijaraeuts.

Case II. Negro woman. Age, a1)out GO years. Fig. 2.
Vertebral formula— C, 7; T, 12; L, 5; ,S', 5.

This subject possessed two well developed cer\ieal ribs,
that on the left side being much better developed tliau that
on the right. Each rib consisted of head, neck, tubercle and
shaft. Each articulated with the seventh cervical vertebra in
two places — the liody and the transverse process. The right
rib articulated with the superior border of the first thoracic
rib, G.9 cm. from the head of the latter. The left rib was
ankylosed with the superior border of the first thoracic ril),
the central point of the ankylosis being 5.5 cm. from the
head of the thoracic rib.

The general shape of the two ribs was the same, the upper
part of the shaft being broad and flat and then rapidly nar-
rowing down to a shaft which was triangular in cross-section.

Each rib presented two grooves. One (1) which was very
well defined, was on the anterior surface of the narrnw pail
of the shaft for the }ias.sage of the lower trunk of the brachial
plexus and the sid'clavian artery. The other groove (2) was
very slight and extended outward across the broad upper part
of the sliaft for the ]mssage of the seventh cervical nerve.

The dianieier of tlie first thoracic rib on the left side from
its lu'ad to the ankylosis with the cervical rib, liu( more
especially in llw nock, was much less than tbat of tbe right
thoracic rib in tbe same part. Beyond the ankylosis it was
nbdnt the same width as the right rib was lievmid its articnla'-
tion with the cervical rib.

From the ti|> of the right t'ci'vical rib a round lilu'ous coi-il
extended to Ihe sternum along the superior bordei' (if Ihe
first thoracic rib, being closely adherent to the latter. A
similar cord was present on the superior border of the left
thoracic rib, being continued from the ankylosis.

The ]n'iiu-ipal measurements of the ribs were as follows:

Right. Lett.

Head, neck and tubercle 3.6 cm 2..S cm.

Straight line from back of tubercle to

end of rib 4.7 " 4. .5 "

Length along' concave border .5.7 " O.ti "

Breadth of upjier part of shaft l.o " I. .5 "

Diameter of lower part of shaft 4 '' .6 "

Diameter of neck of first thoracic rib 1

cm. from its head 9.5 " .5.5 **

On the right side, the scalenus anticus had a. normal origin,
but was inserted on the tip of the cervical rili anil on the
sitperior border of the first thoracic rib for 1 cm. anterior to
the articulation of the two ribs. The scalenus medius was
inserted along the superior border of the cervical rib from
the tubercle to the upper border of the groove for the sub-
clavian artery and lower cord of the brachial plexus, 2.3 cm.
from the distal end of the rib. At the lower end of the
insertion some of the filn'cs were prolonged downwards across
the inner surface of the supplementary interspace to be
inserted on the upper border of the first thoracic rib for l.l
cm. jjosterior to the articulation with the cervical rib. The
scalenus posticus was inserted on the outer border of the
cervical rib at a point l.t! cm. from the tubercle, in connec-
tion with the scalenus medius, and thence by a fibrous band,
.3 cm. wide, backward and downward to the superior boi-der
of the first thoracic rib for a distance of .5 em. on that rib.

The supplementary interspace on the right side was fillett
by two well developed intercostal muscles, an outer and an
inner. The external intercostal arose from the outer inferior
border of the cervical rib from the head to the extreme end
of the rib. The fibres extended downward and forward to
be inserted along the superior border of the first thoracic rib.
The fibres arising from the end of the cervical rib spread
out in a fan-shaped insertion along the anterior face of the
first thoracic rib for a distance of 2.5 cm.

The internal intercostal muscle arose from the inner border
nC the infi'i-idi- sni-face of the rib, the fibres running down-
ward and backward to be inserted along the inner border of
the first thoracic rib for a similar distance. This muscle was

116

JOHNS HOPKINS HOSPITAL lUTLLETIN.

[Nos. 121-132-123.

innervatoil liy (ibrcs from the interfostal ln-aiu-h of tlie first
tliorMcic iKTVt'. This branch ran ahiii<>- tlie superior border
of tlie second tlun-acic rib and sent its fibres across the first
rib io the su|)plcmeutary intercostal muscle.

Tlie eifihtli cervical and first thoracic nerves united at the
inner boi'der cd' the cervical rib to form the lower trunk of
the brachial plexus, which crossed the rib above the subcla-
vian artery. Just i)efore uniting with the eighth cervical
nerve, the first thoracic gave off a slender blanch which de-
scended along the inner border of the rib, behind the sulj-
davian artery, to the lower end of the rib, where it turned
upward to gain the surface, wound around the end of the
rib and was distributed to the articular ligament.

The right rib articulated freely with the seventh cervical
vertebra and also with the first thoracic rilj. A stellate liga-
ment held the head of the cervical rib to the vertebra.
Besides this ligament there was a superior costocentral liga-
ment (3) passing from the superior surface of the neck of
the rib mainly to the lower outer border of the body of the
sixth vertebra, a small slip being continued upward and out-
ward to the anterior inferior border of the transverse process
of the same vertebra. A capsular ligament (4) held the
tubercle of the rib to the transverse process of the seventh
vertebra.

The disposition of the soft parts of the left side' was very
similar to that of the right. The scalenus anticns was
inserted by a fan-shaped set of tendinous fibres to the lower
half centimeter of the cervical rib, and was continued along
the superior border of the first thoracic rib for 1.6 cm.
anteriorly. The scalenus medins was inserted along the
superior external border of the cervical rib from its head to
the upper margin of the groove for the subclavian artery,
2.3 cm. from the central point of the ankylosis. The
scalenus posticus was inserted on the superior border of the
first rib. The iliocostalis dorsi sent a sliiJ of insertion to the
external border of the cervical rib and also one to the tubercle.
On the right side the slip to the tubercle alone was jjresent.

The external intercostal muscle in the supplementary inter-
space was well developed. It arose from the outer border of
the inferior surface of the cervical rilj from its head to the
ankylosis. The fibres, running downward and forward, were
inserted along the superior border and external surface of the
first thoracic rib for a somewhat longer distance. The inter-
nal intercostals arose from the inner inferior border of the
cervical rib, from the ankylosis to the tubercle, and extended
downward and slightly backward to l)e inserted for a similar
distance along the superior inner border of the first thoracic
rib. The innervation of the supplementary intercostals was
similar to that on the right side — l.iy branches from the first
intercostal nerve.

The left cervical rib articulated freely with the seventh
cervical vertebra, but was firmly ankylosed with the superior
border of the first thoracic rib, the ankylosis covering a dis-
tance of 2.2 cm. The tubercle articulated with the transverse
process of the seventh vertebra, the joint being effected by a
capsular ligament, no distinct division into smaller indi-

vidual l)ands being noticeable. From the ui'ck of the rib.
.just within the tubercle, a filirous band (5) .•"> em. in width
extended upwai'd, backward and slightly inward to the lower
])osterior border of the transverse process of the sixth ver-
tebra, and to the anterior face of the transverse process of the
seventh. A small ligament (fi) connected the superior ex-
ternal margin of the liead with the lower, outer border of the
body of the sixth vertebra. Just internally to this, and
arising friuu the middle of the superior surface of the lu'ad.
a band .3 cm. wide (7) extended u})ward ami inward to the
lower outer border of the sixth vertebra, the insertion being
under and inside of that of the smaller slip. Posteriorly to
these, another ligament, .G cm. wide, connected the superior
posterior surface of the head with the lower border of the
body of the sixth vertebra. A shoi't, tough, fibrous cord (8)
extended from the inferior surface of the head of the cervical
rib to the superior surface of the head of the first thoracic rib.
From the upper half of the head of the cervical ril) a stellate
ligament extended to the body of the seventh vertelira.

The arterial distribution on both sides was normal except
for the origin of the left common carotid from the innominate
artery immediately after the latter left the aorta.

There was a distinct skoliosis to the left side in the upper
thoracic region.

Case III. This was simply a cleaned specimen of a rib
from the anatomical museum. Nothing was known about the
subject from which it came.

The specimen was that of a left first thoracic rib, having
a cervical rib ankylosed with it. The ankylosis was so com-
plete and the free part of the cervical rib so shoi't that it
would be better to class this as a bicipital first thoracic rib.
Its morphology is very similar to that of the bicipital ribs
described by Turner.' The rib presented two heads, two
necks, two tubercles; and, for a distance of l.G cm. beyond
the tubercle of the upper division, there were two shafts.
That point marked the posterior limit of the ankylosis, which
extended forward a distance of 4 em. On account of the
ankylosis, the rib was very broad at this part, being 2.(i cm.,
while the true shaft of the first thoracic rib beyond the fusion
was hut 1.7 cm. The two necks were separated by n space
.6 cm. wide.

The principal uieasui'cments of the rib were as foUow's:

From tip of lie.ad to outer border o£ tubercle, (upiier divisiou). .'3.4 em.

II '• " ■' " " (lower division). S.li "

Widtli of necl<, (upper division) S "

" " (lower division) ... .7 "

Straight line from head of lower division to dist;il end of rib. S..") "
Length along convex margin from head of lower division to

distal end of rib 1'.>.3 >■

The U]ipcr border of the rib ])resented two grooves, one
crossing just anterior to the central point of the ankylosis and
the other .7 cm. anterior to this. In the recent state the
subclavian artery and lower cord of the brachial plexus un-
doubtedly crossed by the former, while the latter was prob-

' Journ. Anat. and Physiol., 1883, vol. xvii, pt. ill.

Ai'Ril-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

117

ably for the passage of the subclavian vein. Between these
two grooves there was a very prominent pointed process, pro-
jecting 1 cm. beyond the upper border of the rib. The
anterior margin of its base was also the anterior limit of the
ankylosis. From its general direction and from the fact tliat
there was a visible groove along the line of ankylosis, it seems
probable that this represented the tip of an originally free
cervical rib. In the recent state there was probably a tibrous
(Mird extending from the tip of the process to the slernnni.

SOMMAKT.

Of tliese three cases, the first two present some uiicoiiinion
\ariations. In the first case the innervation of the supplo-
iiiciitary intercostals by a direct intercostal branch from the
eiglith cervical nerve has been described only once." The
second ease shows a peculiar insertion of the serratns posticus
on the first thoracic rib. This has also been described by
Grubcr,' but it is not mentioned as a variation in the standard

* Mem. de 1' Acad, des Sc. de St. Petersbourg, 1869.

text-books, nor is it spoken of by Le Double.^ This case also
presents the following variations, wliich, so far as I can find,
liave not been reported heretofore: a minute brancli from the
right first tlioracic nerve to the articidar ligament l>etween
tlie cervical and first tlioracic ribs; a ligament connecting tlic
licad of tlic left cervical rib witli the head of the left first
thoracic rib, and a ligament from the neck of the cervical ril)
to the lower border of the transverse process of the si.xth
vertebra (Fig. 3, 5). I^or a full list of references to the sub-
ject of cervical I'ibs the recent article by I'hillips' may bo
consulted.

In conclusion 1 wish to express my thanks to Dr. K. ().
Harrison, at whose suggestion the work was originally under-
taken, for his advice and assistance in my work.

■' Traite des variations desSystcme masculaire de 1' liommo. Paris ISltT.
Tome I.

* Jouru. Aiiat. and Physiol., l',)00, vol. xx.\iv, D. s. xiv, pt. iv.

ON THE PRESERVATION OF ANATOMICAL MATERIAL IN AMERICA BY MEANS

OF COLD STORAGE.

By Abram T. K
Assialaiit Profc.tsor of Anaiumij,

The pi'cservaliun of the dead body and its pre}iaration for
dissection ha\e always been problems to the teacher of anat-
omy. The methods of preservation are different according
1(1 the object in view; certain methods being employed when
it is only desired to keep the body for the ordinary dissection;
others, when special parts, systems, or regions are to be
worked out; and still different methods when it is desired
to store material for months or years. One great step was
made in the process of preservation of anatomical material
for dissection when Frederic Euysch, the Dutch anatomist,
introduced the method of embalming by means of injection.
This was further developed by William Harvey and has been
brouglit to great perfection at the present day both by the
anatomists and the professional embalmers. The various
methods employed in most of the principal European schools
have been carefully described by Dr. Iljalniar Gronoos in the
Auatoniischer Anzeigcr for September 28, 1898; and a report
upon the various methods employed in America was jirepared
by a committee of the Association of American Anatomists
and ]iublished in Science January 17, 189G.

The ra]iid development of medical education has called
for the introduction of more lalioratory work in the first two
years of the course, and this, together with the increased
tendency to concentrate medical teaching in the larger col-
leges, has made it necessary to collect dissecting material
during the whole year and to develop methods which shall
preserve it in good condition until wanted.

The method of pickling, that is, placing the body after it

ERR, B. S., M. D..

Cornell Uiiircrsili/. Il/nira, N. Y.

is embalmed and injected into a large vat of brine or some
other fluid, is being quite generally abandoned. It is re-
placed in some institutions by enclosing the bodies in tightly
sealed boxes, in which there is an inch or more of alcohol on
the bottom and the body is surrounded by alcohol vapor. In
other places the use of cold is employed to keep the bodies
until they are needed.

Cold is produced according to the well known law of
physics, that heat is required to change a solid into a liquid,
or liquid into a gas. This heat is abstracted from surround-
ing substances. For the preservation of cadavers the cold
was produced until the past few years by the melting of ice.
either alone or combined with salt. But within recent years
refrigerating machinery has been so well perfected, and the
cost of these machines has been so much reduced, that to-day
there are ten medical colleges in the United States whicli
have installed refrigerating plants. The principle on whicli
these machines work is very simple. It is well known that
it requires much more heat to vaporize a liquid than to
li([ucfy a solid; thus to liquefy 1 gram of ice_ it requires 80
heat units, but to vaporize 1 gram of water it takes 537 heat
units. Therefore in the freezing machine a volatile li(|iiid
such as ammonia or ether is used. The machines on the
market to-day are mostly ammonia machines.

The first ice machine to be used to preserve dissecting mate-
rial was installed by the College of Physicians and Surgeons,
Columbia University, New York, and when it had been in
operation long enough to show the practicability and advan-

118

JOHNS HOPKINS HOSPITAL BULLETIN.

LN,

iai-122-123.

tages of this method plants were installed 1\y the Johns
Hopkins and by the University of Pennsylvania and later
by Syraense University, Long Island College Hospital, the
University of Buffalo, Jefferson Medical College, the Univer-
sity and Bellevne Hospital Medical College, Cornell Univer-
sity Medical College, New York City, and a iilaiit is to be
liuill this year by the Cornell I'liiversity Medical College at
Ithaca, N."y.

Last A])ri], at the siigge.Midn (d' Dr. .Mnll. I |iiesi'nted
before the Association of American Anatomists at Washing-
ton a very brief account of the plant installed at the Univer-
sity of Buffalo. At this time 1 wrote to the pnifessors of
anatomy in all the institutions where 1 knew that they had
cold storage plants and askeil for certain statistics in order to
compare their residts with those obtained by me at the
University of Buffalo. From some of these which I am per-
mitted to use, and from the articles of Dr. iMall ' on the cold
storage plant at the Johns Hopkins, and of Hr. Ibilnies' on
that at the University of Penn.«ylvauia, I wish to call atten-
tion to those things which it is desirable to incorporate in a
plant and those which slunild be avoided. I desire at this
I'.dint to express my thanks to the professors in the institu-
tions named above for furnishing me with data regarding the
ice machines and vaults employed by them.

There are two systems in use at the present day. In the
ammonia-absorption system a solution of ammonia in water is
heated, the ammonia gas passes off into a condenser where
the constant distillation raises the pressure and the heat being
absorbed by a stream of cold water, the ammonia becomes
liquid. The liquid ammonia is conducted to the refrigerating
coils, where it again becomes a gas and by thus vaporizing
produces cold. The gas then passes to another chamber,
where it is absorbed by a weak solution of ammonia in water,
and the strong solution resulting is returned to be heated
again. This type of apparatus is said to have some advan-
tages over the other system, as its relative cheapness and lack
of complicated machinery, but it is also deficient in several
respects. The Long Island C(dlege Hospital is, I believe, the
only medical school which has an apparatus of this kind.

The ammonia compression machine is the one most gener-
ally used to-day. This consists essentially of three parts,
as shown in the figure of the plan at the Johns Hopkins
University. The evaporating coils arc the inpes in which
the liquid ammonia changes to a gas and absorbs heat from
its surroundings. The compressor is a combined suction and
compression pump which draws the ammonia vapor from the
evaporating coils and forces it under pressure into the cooling
coils. These are long lines of pipes immersed in running
water, and under the combined action of the ])rcssure from
the pumj) and cold from the water the ammonia gas is here
reconverted into a liquid and passes again into the evaporat-

ing coils. The lldw is of course regulated l)y valves and pres-

' Franklin P. Mall, The .Anatomical course and Laboratory of the .Johns
Hopkins University, Bulletin of the .Johns Hopkins Hospital, Baltimore,
May and June, 18!)6, vol. vii, Nos. 62-63.

• E. W. Holmes, Refrigeration as a means ol preservation of Bodies
for use iu the Dissecting room, Internal. M. Mag. Phil., ISIIT, vi, 747-741).

NV.^^ \\\\\\\ \vCv

a ~

■/,

'-s

fcti

^_,

o f^'

2 *
o

sure gauges. The compression machines are utilized in two

Apkil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

119

ways. In the one the evaporating or expansion pipes are
distributed directly in the room which it is wished to cool;
in the other these coils arc distributed through calcium
chloride brine and the cold brine is pumped througli the

Jfachines are rated in two ways, according to their ice-
making capacity, and their refrigerating capacity. The latter
is usually taken as twice the former. The unit of ice-making
capacity is one Ion of ice at 32 degrees F. frozen from water

Insulation

^Tine tartK

Fig. 2. — Outline of the cold storasje vault at the Uuiversity of Penusylvania. The brick wall ou the outside is striated.

Fiu. '■'). Section of the cold storas;e vault at the I'liiversity of Bullalci

rooms which it is desired to refrigerate. The first of these
is known as the direct-e.xpansion method, the other as the
indirect. Johns Hopkins and Syracuse have the indirect and
Pennsylvania and Buffalo the direct.

Fig. 4. — Section of the wall and insulation of the vault at
the University of Pennsylvania. BP, one layer of building
paper; A, half-inch'air space.

at 32 degrees F., and is equivalent to 281,000 heat units per
24 hours.

It is quite imjiortant to get a machine large enough for
the work required of it. The size will be influenced greatly

120

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-133-133.

by location, insulation, and so fortli. Very satisfactory work
is being done at Syracuse by a macbinc of 3 tons refriger-
ating capacity for a vanlt of about 3(100 culjic feet. At
Buffalo a 3-ton machine for about 1.500 cubic feet, at Johns
Hopkins a 4-ton machine for 3300 cubic feet, at Pennsyl-
vania a G-ton is used for about 4300 cubic feet. The cost
of such a plant varies from $3000 to $3000.

AVhetlicr the machine works on the plan of direct radiation
or indirectly by means of brine, it is a very great advantage
to have within the vault a considerable body of brine which
is cooled when the machine is running and which holds the
cold, giving it out gradually and keeping the temperature of
the vault from rising rapidly when the machine is not run-
ning. These brine tanks are cooled by coils of ammonia
expansion ])ii)es running through them. In the Johns Hop-
kins plant, where this device was first introduced, there is

around the sides of the upper jiart of the vaidt or along the
ceiling, or botli. This also heljis the circulation and })re-
vents a warmer stratum of air from collecting above and a
cold stratum Ijelow. The circidation of the air in the vault
is only maintained during the running of the machine, as
the temjierature of the e.xpansion pipes soon becomes the
same as that of tlie surrounding air when the machine is shut
down.

The size of the machine rc(|uired is of course influenced
greatly by the size of the vault and its insulation, and the
number of hours per day which the machine is in operation.
In all of the above-named plants there is more than enough
cold produced. The excess of cold can be used to cool some
of the dissecting rooms in summer, as is done at Columbia
and at Cornell, N. Y.

The construction of the vault is one of the most important

Fig. .5. — Section of the iusulatlou of the ceiling of tlie vault at the University of Buffalo, li, BoarJs
space one-inch wide; /', buihiiug paper.

-inch thick ; .1, air

Fio. 6. — Section of the insulation of the side walls of the vault at the University of Buffalo. ,S'ir, stone wall; P, building p.iper.

one large tank situated in one corner of the vault. Since
they use the indirect method tiiis tank alone is cooled by
ammonia expansion coils and the cold brine is taken from the
tank and pumped througji the pipes in the vaidt. At tlie
University of Pennsylvania there are two long, narrow tanks
situated on each side of the door. The brine is ntit ]>umi)ed
from these, but they simply act as a reservoir for cold brine.
At the University of P)ufl'alo there are two long, shallow
brine tanks, which are susjiendod, covering the whole top of
the vault. The advantage in this 'arrangement is that the
large mass of chilled brine cools the air above; this falls to
the bottom of the vault replacing the warmer and lighter air
there, and in this way a constant circulation is kept up (Figs.
1, 3 and 3).

Besides the expansion pipes in the brine, there is a consid-
erable amount of pipe in the vault to cool the air directly.
The arrangement of ammonia expansion coils is usually

things and the aim should be to get the insulation as jierfect
as possible. Willi a perfect insulation there will be al)solutely
no loss of cold and a temperature once obtained will be
retained indefinitely. Of course a perfect insulation cannot
be secured, but a little extra expense in the construction of
the vault at the start is a saving in the end, as the machine
will have to be in operation for a much shorter time. The
illustrations show the method of insulation employed at the
University of Pennsylvania and the University of Buffalo.
These consist of a number of dead air spaces se])arated by
boards and building, or tar pajier. Some of these air spaces
may be iilled with cork or mineral wool. With the consid-
erable changes in temperature and consequent expansion and
contraction the insulation is liable to be destroyed. This
may be partly overcome by having around' the outside a
strongly braced wall, or one of brick or stone, as at the Uni-
versity of Pennsylvania and the University of Buffalo. It is

April-Mat-Junjj, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

121

important that the Audi- sIkuiIJ lie well insulated and covered
on tlio inside with a layer ot Portland cement, asphalt or,
better still, sheet zinc, which should extend up for a toot or
so on the side walls of the vault. It is desirable also tluit
the floor should slope toward the entrance, so that wlien the
machine is shut down and the vault is being cleaned, the
water will flow through the door to a drain placed in the
room outside.

With a vault of a given size the capacity in bodies varies
according to the method of storing them. There are three
methods in general use in the different universities. The
most popular is to have the vault arranged with a series of
shelves. This is the method employed at the Universities of
Buffalo, Pennsylvania, Syracuse and Long Island College Hos-
pital. At the Johns Hopkins the bodies were first stored on
shelves but in order to increase the capacity of the vault the
shelves were removed and the bodies piled one upon an-

JaL

(( m

ifQ

Fiii. 7. — Side of vault showiiiiic the arrangement of the expansion
pipes at the University of Kiiti'alo.

other. At Columbia and Cornell, N. Y., they are suspended.
There are certain advantages in each system. The method
of shelving the l)odics-takes up the most room, but it has the
advantage that each body is easily accessible. The shelves
may be divided into sections and each shelf numbered, then
when a body is placed in the vault the record of its position
can be added to the department history and it can readily be
found when desired for a particular purpose. In actual prac-
tice tliis works out very nicely, as employed at the University
of Pennsylvania, and a body which has been stored for months
and is then claimed by relatives is easily located. The
slielves may be either made of slats or solid boards. The
latter are used at the University of Buffalo. AVIiere the
subjects are piled one upon the other there are several advan-
tages as well as disadvantages. First of all there is great
economy of space, and the subjects being packed closely tend
to prevent evaporation, but on the other hand there is a
tendency for the bodies to become frozen together, causing
considerable annoyance when one is to be removed. This

has been overcome by Dr. JInll liy placing a layer ol' building
lathe between the bodies after they have been vaselined and
wrapped. Of course in a great pile of bodies it is very diffi-
cult to find any particular one. Bodies packed in this way
tend to hold the cold for some time, so after the machine is
shut down and the vault thrown open it takes several days
for them to thaw out. If these bodies are piled closely around
a brine tank it is still more difficult to thaw them with the
additional cold from the tank, and this is a great advantage
in case of a break-down.

At Columbia and at Cornell, N. Y., the bodies are sus-
pended and run into the cold storage vaidt on tracks like
the carcasses at a slaughter-house. I do not know the ad-
vantages and disadvantages of this method.

The temperature in the vault should not be allowed to run
.above freezing, as this permits thawing, and in consequence a
slopj)y condition of the floor. The average maximum tem-
perature usually maintained at the University of Pennsyl-
vania is 24 degrees and the minimum 16 degrees Fahrenheit,
and at the University of Buffalo the maximum is 2.5 degrees
and the minimum li degrees Fahrenheit. This is computed
from (he daily temperatures for June, July and August, 1899.
which are given in the appended table. These temperatures
are taken at the University of Buffalo by an ordinary ther-
mometer, it being necessary to enter the vault to take the
readings. At the University of Pennsylvania a self-recording
thermometer takes the temperature variations.

All of the vaults are lighted by electricity, which may be
turiuHl on by a switch from the outside Ijefore entering the
vault. The cost of operating a plant varies greatly, depend-
ing on the size, number of hours a day it is run, number of
subjects, and also the motive pow'er.

Steam is employed to operate the machine at the Johns
Hopkins and at the Long Island College Hospital, and steam
with electricity as reserve at Syracuse University. Electricity
alone is used at the University of Pennsylvania, and a gas
engine at the University of Buffalo. As the steam is also
used for heating and the electricity for lighting it is difficult
to estimate the exact amount of either used for running the
machine. At the University of Buffalo and at the Johns
Hopkins an estimate of the cost for one year was below $100.

In all the cases before the body is placed in the cold room
it is endialmed and the arteries filled with colored plaster,
starch or at the Johns Hopkins with shellac. When wanted
the body has only to be taken from the vault to the dissecting
room and upon thawing it is ready for work. When a body
is kept in cold storage for a time there is considerable drying
of the hands and feet, face and genitals, and when kept for
a long time there is a general mummification of the body.
To overcome this the body is covered at tlie Johns Hopkins
with a layer of vaseline, over which is wrapped a layer of toilet
paper, and the whole is covered with cheese-cloth. The same
method is employed at the University of Pennsylvania. At
the University of Buffalo and at Syracuse L^uiversity only the
head, limbs and genitals are w-rapped.

Although there are other methods of preserving the body

122

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

for dissection, it would seem that a well embalmed body
properly wrapped and kept in cold storage furnishes the
cleanest, best preserved and most satisfactory dissecting ma-
terial. Besides being used to preserve cadavers the refriger-
ating plants in the different medical schools are used to keep
such material from the slaughter-house as is used for dis-
section. Fresh organs from post mortems are also preserved^
in the vault until wanted, or a sepai-ate compartment, cooled
by the same machine, is built to contain them.

From the study of the various cold storage apparatuses
for the preservation of anatomical material it appears that
the system at the Johns Hopkins is the most economical, as
it does not require continuous operation of the machine.
This system is further improved at the ITnivcrsity of Penn-
sylvania and at the University of Buffalo for the direct
system of cooling the vault at the same time the brine tank
within the vault is chilled makes the pumping of brine un-
necessary.

TABLES OF RESULTS OBTAINED DURING JUNE, JULY AND
AUGUST, 1899 AT THE UNIVERSITY OF BUFFALO.

The machiue was operated only durins; the day, the uumbers below
13 are A. M., and those after 13 are P. M. The temperature is given in
degrees Fahrenheit.

Maximum

M inimura

Date.

Duration of Run.

Time.

Temp.

Time.

Temp.

;i899.

June 1

4 hrs.

24°

16°

3)4

13 •

Sunday.

2Ji

3)i

Ifi

43^

Sunday.

Engine out of order.

July 1

Sunday.

iJ''

18
13

Holiday.

Sunday.

Maximum

Minimum

Date.

Duration of Run.

Time.

Temp.

Time.

'I'cmp.

1899.

Julvl4

3% hrs.

34°

1.5°

i'A

Sunday.

3>^

Sunday.

3}^

. Sundaj'.

Aug. 1

Sunday.

3?i

Sunday.

■m

3/2

4J^

Sunday.

3 'A

Sunday.

*'A

^•A

• 34

TEMPERATURE RECORD ANATOMICAL VAULT MEDICAL
DEPARTMENT UNIVERSITY OF PENNSYLVANIA.

The temperature is given in degrees Fahrenheit.

Date.

Dumtion of Run.

Maximum
Temp.

Mitiimnm
Temp.

1900.

Aug. 26
37
38
29
30
31

Sept. 1

4
5
6

7
8
9
10
11
12
13

8 hrs.

5°

3°

U}i

i-^K

12}^

13}^

13>^

15J^

15j^

10.4

15;^

Apeil-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

123

Date.

Duration of Run.

Maximum Minimum

Temperatubi

IN Degrees Fahrenheit.

Temp. Temp.

Date.

/6u

tside.

Brine

Vault^

1900.

1.5

.5 hrs.

14i.3° 7°

13 7

14 9

1893.

A.M.

P. M. A

M. P

A.M.

P.M.

Duration
of Run.

15 15;^

November

21..

0 hours

16 8

22..

. 60

n ^'A

23..

. 63

9 5>^

24 .

13j^ 10

25..

. 62

O'i

16 10^

26..

. 73

16 9

27. .

. 70

15 12

28..

2.5

16 9

29..

. 60

15 8J^

30..

. 70

14>^ 9
14-^ 8

December

1. .

. . 64

13|^ 1 1

S..
4..
5. .

. 63
. . 56
.. 57

,68
57
64

27
28

30
26
29

8
0

The above table was compiled from five discs, loaned by
Prof. Piersol, on which the temperature was recorded aiito-

6. .

7 . .
8 .

. . 56

. . 5S

63
64

29
30

30
31

0
0
0

iiiatically. Each disc recoi
miiiibcr of hours during wh

ded a
icb tb

week's temperature. The
c machine was in operation

9. .
10. .
11..

. . 60
.. 58
. . 59

66
67
70

25
11

8
1

32
32
26

32
23
27

8
8

(by electricity)

was estimated fro

n the interval between the

12..
13. .

. . 60
59

64
63

28
29

39
30

0
0

rii^e and fall o

■ the tempei

ature

curve. There is an incon-

14.'.

. . .58

stant interval, after the machine lias stopped, during which
tlie temperature does not rise appreciably. This was esti-

1.5. .
16..
17..

'.. 49
. . 68

48
78

32
32

32
24

0
0

iimtcd to be aliont one liour

and h

as lieen deducted in makino-

IS. .

.. 70

19. .

. . 70

(lie above tabk

20 .
21..

.. 68
.. 67

68
69

31
33

TE.Ml'EKATURK

RECORD OF

THE BRINE AND VAULT AT THE

ANATOMICAL LABORATORY OF THE JOHNS HOPKINS

23.'

. . 60

UNIVERSITY.

24.
25 .

.. 73

Tlie niacliiiu' was operated only part

of tlie time, the object being to

26.

. . 76

determine liuw

well the insu

latiou

of the vault would hold the

27..

.. 73

temperature belo

V the freezing

point.

28.
29.
30.

.. 74
68

(1
0

Temperatdre in Degrees Fahrenheit.

31.'.

'.. 66

-^^

189(

Date.

/outside.

Brine. Vaull.^

Januarj

• 1.

1895.

A. M. P. M.

A. 51.

P M. A. M. P. M. Duration

.' .' 68

<,f Run.

3.
4.
5.

.. 68
.. 64

74
TtS

29
30

30
31

0
0

November 11. . . .

.59 69

39 25 8 hours

12....

59 62

29 25 2

. . 58

fil 61

28 25 8

.. 60

62 73

0 26 21 8

.. 64

»).

1.5

72 78

24 23 9

. . 68

l(i

71 78

5 24 20 4

10.

. . 66

17...

11.

63 69

5 37 23 6K

12.

19...

71 68

6 25 21 7

13.

.. 61

70 73

2 26 21 8

14.

.. 68

ON THE DEVELOPMENT OF THE NUCLEI PONTIS DURING THE SECOND AND THIRD

MONTHS OF EMBRYONIC LIFE.

By Mahgaeet Long.

[From the Aiiatojitii'iil Laboralori/ of Johna Ih'pkiita Vnu'erxitij.)

This work was undertaken in the fall of 1899 at the sug-
gestion of Doctor Barker, and has been carried out with his
assistance. The specimens used are human embryos and
were very kindly lent by Doctor Mall from bis collection.'

' The numbers of the embryos correspond with their numbers in the
embryological cabinet of the Anatomical Laboratory of tlie .lohns
Hopliins University.

The following emljryos are described in the order of their
probable age, as estimated by their length and by the devel-
ojiment in the rliombencepbalon. The arrangement of the
cerebral nerves and the general appearance of the medulla
oblongata agree with the His models and with the descrip-
tion given l)y His in "Die Entwicklung des menscblicben
Kautenhirns"; a description of these is accordingly unneces-

124

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

sary. Each embryo has been studied in serial sections and
from tliese sections a few, at different stages of development,.
have been selected as characteristic of the structure of the
pons, its nuclei and fibres. To make the work complete it
will be necessary to study more embryos at intermediate stages
between the five given here, and others from the third montli
up to the adult ))ons.

Embryo No. LXXV is 30 mm. long and has been cut into
serial sagittal sections. The nuclei, whiuli I have designated
as " B," " C," " D," " E " and " H " in the various sections,
are masses of cells distributed through the ventral part of
the mantle layer (Mantelsehicht of His) at or near the level
of the pontal flexure. The most medial of these nuclei ex-
tend to within 0.7 mm. of the middle line. An unstained
fibre bundle can he .seen on the surface of the rhombenceph-
alon ventral to the mantle layer throughout its entire lengtli.

Section No. 73 is 2.1 mm. to the left of the middle line
(Fig. 1). Near the ventral surface on the cerebral side
o.f the nervus trigeminus is a well defined cell-mass, '" B.'
On the ventral surface opposite the nervus acusticus is a
deeply stained cell-mass, " IT," which (wlien followed in the
series) is seen to extend lateralward and spinalward to the
floor of the fourth ventricle at the Junction of the latter
with the telachorioidea. The section of the mantle layer
presents longitudinal striations which have a slight ventral
convexity. A few of these strands are more deeply stained
than th.e rest between the level of the N. trigeminus and that
of the N. acusticus. The dark ependymal epithelium and
the unstained ventral fibre bundle are evident.

Section No. 91 is 1.2 mm. to the left of the middle line.
On the ventral surface of the pons is a delicate shell or mass
of cells, " H," continuous lateralward with " H " of the
previous section. Between it and the mantle layer is the
ventral fibre bundle. Dorsal from " A " is a cell-mass, " C,"
partially subdivided by a few colorless dorsoventral stripes;
ventralward and cerebralward from " C " is another mass,
" D," and still more cerebralward and dorsalward are two
small deeply stained cellular masses, " E." The mantle layer
of the medulla oblongata is deeply stained. It contains a
diamond-shaped mass, " S," spinalward from " C," the longi-
tudinal striations mentioned in the previous section, and an
unstained dorsal filire bundle (DF).

Section No. 96 is 1.05 mm. to the left of the middle line.
"H" and "C" are still present. The ventral fibre bimdle
passes partly along the dorsal surface of "H" and partly
between " C " and " E." Just cerebralward from the pontal
flexure, close to the floor of the ventricle, is " M,'' an oval
mass of cells witli a clear unstained area behind at its spinal
end, and measuring 0.8 mm. in transverse diameter. The
appearance of the mantle layer is the same as before. In its
dorsal and cerebral part is seen an unstained dorsal fibre
bundle.

Embryo No. LXXXVI is 30 mm. long and has been cut
into serial coronal sections. There is ventralward a definite
mass which I have designated as the nucleus pontis ventralis;
it is about 1 mm. long by 3 mm. wide. The raphe enters

this nucleus in the middle line. Dorsal from its lateral part
are several scattered masses which 1 have designated, tenta-
tively, the nuclei pontis dorsales. The unstained ventral
fibre bundle is dorsal from the nucleus pontis ventralis.

Section No. 175 is spinalward from the masses mentioned.
On the ventral surface medialward from the nervus acusticus
(-A^.l ) is the cell-mass " H." Followed through the series
this cell-mass extends spinalward, dorsalward and lateralward
to the ependymal epitlu^lium of the fourth ventricle; cerebral-
ward, it is medial to the nervus trigeminus and continuous
with the nucleus pontis. Taken in order from the raphe
lateralward in the mantle layer are the nucleus olivaris supe-
rior (8) and the superior olivary complex {S}, the ascending
and descending parts of the root of the nervus facialis, the
nucleus nervi facialis {NNP), and the corpus restiforme {OR).
On the floor of the fourth ventricle are the nucleus nervi
abducentis (NNA) and the nucleus N. vestibuli (radicis de-
seendentis), {III? I'D); further lateralward are the nuclei N.
cochleae, namely the nucleus N. eochleffi dorsnlis (NRCD)
and the nucleus N. cochlea; ventralis (NNCV). The un-
stained area is the ventral fibre bundle (I'-P')-

Section No. 184 is 0.45 mm. cerebralward from the preced-
ing section. In the mantle layer are seen in order the nucleus
olivaris superior, (S), the nucleus nervi facialis (NNF). and
parts of the ascending and descending limbs of the nervus
facialis. "H" is on the ventral surface lateral from tlie
nervus facialis. On the floor of the fourth ventricle is the
nucleus N. vestibuli medialis et radicis descendentis (NNV).

Section No. 202 is 0.9 mm. cereliralward from section 184.
The nucleus pontis ventralis reaches lateralward as far as
the nervus trigeminus. In the middle line the raphe extends
from the nucleus pontis to the ependymal epithelium. The
nuclei pontis dorsales consist of several irregular masses, " A,"
" B," " C," and " E," and a more ventral and lateral mass.
" D." These nuclei extend through the pons for a distance
of 0.5 mm. in the cerebrospinal diameter. Between these
ventral and dorsal nuclei is the unstained ventral fibre bundle.
Lateral from the nervus trigeminus are the nucleus nervus
trigeminus ascendcns and an unstained area.

Embryo No. XLV is 28 mm. long, and has been cut in
serial sections, which divide the pons in an oblique direction
in the following way: Instead of corresponding to the trans-
verse diameter of the pons the left side of each section is
further spinalward than the right side of the same section.
The ventrodor.sal plane of the section is also oblique, so that
in each section the left half of the dorsal surface is the more
lateral, but in the right half of the pons the dorsal surface
is more medial than the ventral. In other words, the first
section removes a small portion of the pons about the cerebral
ventral corner on the left side, and at the dorsal-spinnl angle
on the right side.

The nucleus pontis, as seen in this series, is on the surface
of the rhombencephalon and follows the curve of the pontal
flexure so that it is crescentic in shape, with a ventral convex
surface and cerebral and spinal ends or horns. Consequently.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXI.

G.V.

VF
- H.

NT.

Fig. 1. — Section through the pous of erabrj'o LXXV, oO mm. lous;
X 1.5 diameters.

Fig. 3. — Section No. 91 of embryo LXXV, x 1.5 diameters.

N.N.K. N.N.V

NRC.D

■M.R.C V
CR.

Fig. 3.— Section No. 90 of embryo LXXV.

v.r. 5 s.

Fig. 4. — Section No. 17.5 tlirougli tlic brain of embryo LXXXVI, oO
mm. long, x 15 diameters.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXII.

N.NV.

-.c R.

"N.N.F

s s.

N,F.

R— V

Fig. 5. — Sectiou No. 1.S4 throuirb embryo LXXXVI.

^f- N.PV,

Fig. (i,— Sectiou No. 302 througb embryo LXXXVI

N.P.D

N.PD. S

Fig. 7. — Section No. KIO tbrounb embryo XLV, x lo duimeters.

N.PD -

N.RY-
V. F: --

N.PD

-C

-C.R.

.H.

N.A.

Fig. S.— Section 142 tbrougb embryo XLV.

Fig. i). — Sectiou 14.5 tbrouffb embryo XLV.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXIII.

Fig. 10. — Section No. 92 tUrougb embryo XCV.

-^^^^

Fig. 11.— Section No. lUO tlirough embryo XCV.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXIV.

y? ./"^

jaSo?^y?^

./-"'"

ill

^m^

Fig. 13.— .Section No. UIC. tUronsli eniliryo XCV.

TC--

HM-—-i

Fig. 13.— Section No. lOS through embryo XCV.

Apetl-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

125

the following sections may have a ventrocerebral, a ventral, a
veutrospinal and a dorsal edge.

The nucleus pontis ventralis is a solid mass of cells con-
tinuous with the raphe. The nucleus pontis dorsalis ia
divided into right and left halves not continuous in the
middle line. The ventral fibre bundle passes between the
ventral and dorsal nuclei except at their extreme lateral parts,
where the cerebral ends of the two nuclei are united.

Section No. 13G is 0.05 mm. to the right of the middle line.
On the right side the nucleus pontis ventralis is separated
from the raphe by the ventral liljre bundle and nucleus ex-
tends across the middle line. On the left side the two ends
of the nucleus pontis dorsalis are separated from the rajiho
by the ventral fibre bundle and mantle layer. On the veutro-
spinal surface at the level of the nervus facialis is a deeply
stained mass of cells, " H." This mass is continuous oppo-
site the nervus trigeminus with the nucleus pontis; spinal-
ward, dorsalward and lateralward it extends to the ventricular
epithelium of the medulla oblongata. In the medulla is a
cell-mass, " T," on the medial side of the corpus restiforme.
and reaching from the fourth ventricle to the ventrospinal
surface. Between " T " and the nucleus pontis dorsalis is a
small round mass, " S," a little more deeply stained than the
rest of the mantle layer.

Section No. 143 is 3.5 mm. to the left of the middle line
and shows only the left side of the pons. Between the nuclei
pontis is the ventral fibre bundle. The nucleus pontis dorsalis
is in the mantle layer; in its spinal end is a small unstained
space. On the ventrospinal surface is the uuiss " H." Medial
from the corpus restiforme is a round, deeply stained area
" S." Near the fourth ventricle are several dark masses just
like those in section 136.

Section No. 145 is 0.4 mm. to the left of the middle line.
The nuclei pontis ventralis and dorsalis are continuous at their
cerebral ends. Between them is the ventral fibre bundle.
Opposite the radi.x N. cochleae is " H," and median from it
a cylindrical-shaped area. Between the cerebellum and the
pons is an unstained area, the corpus restiforme.

Embryo No. XCV is 46 mm. long and cut into serial
sagittal sections. The nucleus pontis is a solid mass of cells
on the ventral surface of the pons, which has increased in
size and measures 3 mm. in cerebrospinal, 4.6 mm. in trans-
verse, and 0.5 mm. in ventrodorsal diameter. The ventral
fibre bundle divides into two masses, the larger passes dorsal
to the nucleus, the smaller through it.

Section No. 93 is 0.3 mm. to the left of the middle line.
The nucleus pontis is a solid nuiss of cells. Dorsal from it is
a dark wedge-sluiped area; its ventral surface reaches as far
as the nucleus pontis and extends 0.4 mm. beyond the middle
line on each side, the dorsal surface is continuous with tlie
ependymal epithelium in the middle line and for a distance ol
0.3 mm. to the right. This area contains ventrodorsal mark-
ings, and small masses of cells staining more deeply than the
rest of the tissue of the wedge between them. On the floor
of the fourth ventricle just cerebral from the pontal flexure
are two dark round cell-masses, " M," which extend through

a few sectjons on either side of the middle line, but in the
middle line are overlapped by the greatly thickened ependy-
mal ejiitlielium. On the ventral surface of the medulla
oblongata is the ventral fibre bundle. Near the dorsal sur-
face cerebral from the pontal flexure is the dorsal fibre
liundle. The mantle layer contains the curved longitudinal
striatiou, and in the isthmus is more deei)ly stained than in
the medulla, and also contains blood-spaces. Next the epen-
(lynuil cpitlielium the mantle layer of the medulla [iresents
a unit'onn appearance, and in the isthnuis it contains several
darker masses ol' cells.

Section No. lOO is 0.6 mm. to the right of the middle line.
The s]>iiwl portion of the nucleus pontis is divided into
ventral and dor.^al parts by a clear area, containing a few
dark strands com}iosed of cells. " M '' is still present; be-
tween it and the nucleus pontis are several small cell-masses.
The ventral fibre bundle is on the surface of the medulla and
next the dorsal side of the nucleus pontis. The mantle layer
contains the curved longitudinal striatiou and blood-spaces.
Between the dorsal fibie bundle and the ependymal epithe-
lium arc numerous dark cell-masses.

Section No. 106 is 1 mm. right of the middle line. The
nucleus pontis is more unevenly stained. Its cerebral end is
divided into ventral and dorsal parts by an unstained area,
which is continuous with the ventral fibre bundle. The fibre
bundle extends the entire length of this section. It is now
seen that this fibre bundle has an oblique direction through
the cerebrolateral and spinomedial portion of the rhomben-
cephalon. The appearance of the mantle layer is the same as
in the preceding section; between the nucleus pontis and the
nucleus olivaris a foAV of tlie curved striations are more deeply
stained than the rest, '' S."

Section No. 108 is 1.4 mm. to the left of the middle line.
The nucleus pontis is a smaller mass, unevenly stained owing
to the presence of large numbers of white spots (nerve-fibres).
Dorsal from it is the ventral fibre himdle. The mantle layer
appeal's as before but the mass " M " is not present. Between
the nucleus pontis and the nucleus olivaris are a few small
cell-masses, and several more are scattered throughout the
mantle layer of the isthmus.

Embryo No. XCYI is 48 mm. long and cut into serial sagit-
tal sections. The nucleus pontis has increased in the ventro-
dorsal diameter. The appearance of this specimen is almost
identical with that of No. XCV, and is only of interest
because it corroborates what was found there. So I have
not thought it necessary to add illustrations. Just spinal
from the nervus trigeminus the nucleus pontis is continuous
with a mass of cells which reaches to the ependymal epithe-
lium of the fourth ventricle. The ventral fibre bundle passes
partly along the dorsal surface of the nucleus pontis and
partly through it. Among the latter fibres are a few scattered
strands of cells resembling more the appearance of the pons
at later stage. The wedged-shaped area and the cell-mass
appear as before.

The histological structure of these specimens is as follows:
The ependymal epithelium contains large, dark, densely

126

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

packed, round and oval cells. The mantle layer in the earlier
stages consists of round cells and a few oval cells. In embryo
No. LXXV an unstained fibrous network is seen and the
round cells are scattered through it, which in No. LXXXVI
and No. XLV are more closely packed together. In the
older specimens neuroblasts of the mantle layer point in vari-
ous directions, a good many of them direct their axones ven-
tralward, and many roimd cells are still seen. Most of the
neurolilasts are now arranged in definite groups; between them
is an unstained fibrous network which contains spongioblasts.
Both the nucleus pontis and the mass " M " are composed
of round cells in all the sections. The mass " H " consists
of round cells, resembling in size and staining reaction those
of the ependynial epithelium. The raphe appears in two
specimens; it consists of filjres which interlace across the
middle line, round cells, ami in the frontal sections a few
oval cells with their long axis transversely directed. In
sagittal sections the raphe is not seen; its fibres, if present,
would be cut in cross-sections.

Summary.

The main nucleus pontis is situated on the ventral surface
of the rhombencephalon at the level of the pontal flexure.
In the specimens the nuclei pontis are first seen on the surface

and in the ventral part of the mantle layer of the lateral part
of the pons Varolii. Ventral to all, in this early stage, except
the mass of cells " H," is the ventral fibre bundle. In the
second embryo the nucleus pontis ventralis extends across
the middle line of the rhombencephalon and the nuclei pontis
dorsales are separated from its lateral part by the ventral
fibre bundle. The nuclei pontis dorsales next form two solid
masses, reaching almost to the middle line. They are still
separated by the ventral fibre bundle from the niicleus pontis
ventralis, except at the extreme lateral ends, where they are
continuous with each other. Next the nucleus pontis be-
comes a solid shell on the ventral surface cut by a .small
branch from the ventral fibre bundle. After the sixth month
the pons consists mainly of fibres and scattered groiips of cells
which increase at the expense of the dorsal part of the nucleus,
while a narrow ventral nucleus or eell-nuiss is left on the
surface.

The neuroblasts of the pons are continuous with the epithe-
lium of the floor of the fourth ventricle:

(1) By the cell-mass " H " at the lateral end of the nucleus
pontis.

(2) By the round cells in the rajjhe.

(3) In the middle line by the neuroblast in tlie wedge,
which connects both the ependymal epithelium and the cell-
mass " M " w ith tlie nucleus pontis.

THE ARCHITECTURE OF THE GALL-BLADDER.

By Mervin T. Sudler, Pn. D., M. D.,

Iiislruclor in Anaioniy, Johns Tloplins University.

During the past few years the development of the surgery
of the gall-bladder and ducts has increased the interest in
their finer anatomy, and various investigations have been
undertaken in order to add to our knowledge in regard to
their structure. The lymphatics and finer blood-supply, how-
ever, do not seem to have had the same attention as the mus-
culature and nerve supply; and so this paper deals more with
this part of its structure and its histology than those which
have been carefully considered in other papers.

The results mentioned here were obtained for the most
part by the use of the gall-bladders of dogs and pigs. They
were used because of their suitability and the ease with
which they could be obtained. A limited number from cats
and beeves were used also. The results thus obtained from
fresh material were verified or refuted upon human gall-
bladders as far as the limited supply and general bad condi-
tion of them allowed. Within a few hours after death the
bile stains and macerates the tissues so that they are quite
changed. The mucous membrane disappears entirely in from
five to six hours after death; the nuclei and tissues under it
refuse to stain, and it is impossiljle to obtain satisfactory
results from any but the fresliest material. For the histology
small pieces hardened, distended and contracted in saturated

corrosive sublimate solution yielded material that stained well
and gave good pictures. For the connective-tissue elements
the most striking picture was obtained by the use of Van
Gieson's acid fuchsin and picric acid, but Weigert's elastic
fibre stain furnished the most accurate and delicate picture.
For the blood-vessels ordinary carmine gelatin mans and
lamp-black or cinnabar gelatin mass were all that were neces-
sary. For the lymphatics a saturated aqueous solution of
Prussian-l)lue proved to Ije the best, notwithstanding a careful
trial of a number of more complicated and presumably better
masses.

The thickness of the wall of the gall-bladder varies accord-
ing to its state of distention. In an adult human sul)ject it
is from 5 lum. thick in a state of distention to 2 mm. in a
state of contraction. The distended gall-bladder of a new-
born infant is nearly J mm. thick. In the pig it may be from
5 to 3 mm. thick, and in a dog of medium size from \ mm.
to 1^ mm. thick. The wall of the gall-bladder is made up
of the following coats: 1. mucous; 2. fibro-muscular; 3. sub-
serous and on the free part covered by peritoneum; 4. serous.
The relative thickness of these coats can be seen in Fig. 0,
wliieli sliows tlie gall-bladder of the dog contracted. The
relations are essentially tlu' same in man as in the dog.

Apeil-Mat-June, 11)01.]

JOHNS HOPKINS HOSPITAL BULLETIN.

127

The mucows layer is thrown into a series of folds from ^
to I mm. high in man. These folds of mucous membrane
cover corresponding ridges of connective tissue of the fibro-
muscular layer and contain an exceptionally rich capil-
lary network. The irregular spaces surrounded by these folds
are much larger at the fundus than at the duodenal end
of the gall-bladder. In man the measurements in the dis-
tended gall-bladder are 3 mm. X 5 mm. in the fundus and
1 mm. X i nim. or smaller near the beginning of the cystic
duct. In the crypts formed by the folds solitary lymph folli-
cles are found. These are more numerous in the dog than
in the pig, and in this regard there seems to be a great deal of
individual vaiiation. The mucous layer is composed of sim-
ple colunmar eiiitlielium, which rests upon an iucomjilete
muscnlaris mucosa. In the dog these cells are from 25-43 />•
thick. These cells seem to secrete a thick mucous material
but no goblet cells are present. R. Virchow (1), in an article
published in 1857, finds tine fat-drops in the ends of these
cells of the gall-bladder and ducts during or just after the
absorption of chyle. These droplets gradually became larger
and worked toward the base of the cell. He thought this
fat had been lost from the liver in the secretion of the bile
and was again picked up by these cells. Nothing was seen
in my preparations to suggest this. Granules were often seen
in the outer end or near the base of the cells, but these gave
no reactions for fat. Belonging also to the mucous layer
were the tubular glands. These were beautifully shown in
specimens stained in gold chloride. There are few of them
in the dbg, but in the pig, and especially in the ox, they are
quite numerous.

The fibro-muscnlar coat is composed of smooth muscle
fibres and interlacing bands of connective tissue. The direc-
tion and arrangement of these fibres has been very carefully
studied by Hendrickson (2). He concluded that in the gall-
bladder there are no definite layers and that the bundles of
fibres interlace in all directions with the greatest number
tending toward a transverse direction. According to Doyon
(3), the muscle fibres arrange themselves in two methods in
different animals: 1. A network with rather rounded meshes.
This arrangement is found in the guinea-pig. This fact has
been corroborated by Ranvier. 2. The muscle fil)res are
arranged into bundles which form a number of principal
directions more or less plainly marked out. This is found
in the dog and cat, and means about the same as the descrip-
tion of Hendrickson. My preparations and sections lead
me to agree with Hendrickson, with the possible exception
that near the fundus in the dog there is an outer and rather
definite longitudinal layer. See Fig. 0. The part of this
layer near the mucous membrane is composed almost entirely
of connective tissue with only a few muscle fibres scattered
through it, the part directly under the epithelium forming a
mucosa which, however, shades ofi: gradually and is not
sharply separated from the underlying tissue. It is in this
region that the thickest plexus of capillaries and intrinsic
lymph channels exists. The solitary lymph follicles, to which
reference has already been made, are found also here just

inider the mucous membrane. Toward the subserous layer,
on the contrary, the muscle fibres are collected into well
developed bundles (especially so in the pig and ox) and the-
connective tissue is corresponding-ly less. Elastic tissue oc-
curs even here, however, varying in form from fine threads
to coarse bands. It is especially abundant in the neighbor-
hood of the blood-vessels. See Fig. 6. Unstriped muscle
also exists in the larger gall-ducts, and at the point where the
ductus communis joins the ductus pancreaticus it becomes
modified into a sphincter. This has been found by Hen-
drickson in man, the dog and the rabbit, and also by Helly
(4) in man, and Oddi (5) in man. The fibro-mnscular layer
contains the larger blood-vessels, which divide into branches
and thus supply the other layers. See Figs. 2 and 6.

The subserous layer is composed of dense interwoven elastic
tissue bands which contain comparatively few nuclei, and
therefore few connective-tissue elements. These bands form
an irregular mesh-work which is denser on the side toward
the serous layer. This layer is poorly supplied with blood-
vessels, although there is a well developed set of lymph chan-
nels which communicate with the large superficial vessels
coming from the liver. By ])nlling the gall-bladder apart it is
possible to divide it into two la3'ers; the separation occurring
at the junction of the subserous and fibro-muscnlar layers.
By separating injected tissues in this manner a very pretty
picture of the circulation in each part can Ije obtained distinct
from the other.

The serous layer is present only on the part covered by
peritoneum, i. e. the fundus, the inferior surface of the gall-
bladder and the outer surface of the gall-ducts. If is com-
posed of simple flat endothelial cells from 4-6 ," thick and
adds but little strength to the organ. The larger lymphatic
vessels from the liver and deeper layers of the gall-bladder
nui between it and the subserous layer.

Brewer (G) has described in a very careful manner the way
the cystic artery reaches the gall-bladder in man and the
variations one would find ordinarily. He found that in 50
subjects only 3 corresponded to the type described in text-
books of anatomy. It is possible to judge from this of the
great amount of variation existing in its blood-supply. The
largest artery after it has reached the gall-liladder is usually
found, however, on its inferior surface and on the side toward
the middle line of the body. There also may be a smaller
branch on the side away from the middle line. This is cov-
ered at first by peritoneum and then penetrates the outer
part (if tlie fibro-muscnlar layer and gives off the branches
which suj)ply the viscus. ]\Iost of tlie larger vessels are in
the fibro-muscnlar layer near the dividing line between it and
the subserous layer. See Fig. C. If the needle of a hypo-
dermic syringe be introduced into one of the smaller arteries
and llie mucous surface be watched while the fluid is slowly
iujecti'd tlie arterioles and capillaries can be seen to be filled
in areas about 2i mm. in diameter at a time from a single
centrally placed artery. The capillaries under the mucous
niemlirane are very niuuercnis and in the folds tlie capillary
nclwdrk is especially lliick. See Fig. 2. The blood from

128

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-133.

these is collected into the veins and returned to the larger
and deeper lying ones accompanying the arteries.

The subserous layer has a comparatively poor blood-supply.
The arteries are small and the capillaries widely separated.
Some of the capillaries run out between this layer and the
serous layer, and thus provide for the nourishment of the
peritoneal covering. Some veins of considerable size are also
found in this layer. On the surface of the gall-bladder in
contact with the liver the veins communicate with the
branches of the portal vein and the arteries in part come
from the hepatic artery.

The large lymphatic vessels running over the gall-bladder
bring lymph from the liver and the coats of the gall-bladder.
They follow the inner side of the cystic duct and end in
mesenteric lymph glands in the dog. In the pig and in man
we have either one or two systems of the large lymph vessels.
In almost all cases both are represented but the territory may
not be equally large and there is wide variation in their
method of distribution. In cross-section these vessels are
always flattened although the degree of flattening varies with
the completeness of the injection. Sappcy (7) figures a mass
of them running over the gall-bladder in a manner somewhat
resembling Fig. 4, but he only mentions the fact that they
bring in the lymph from the liver and deeper layers of the
gall-bladder. In my preparations they run down eventually
on the inner side of the gall-bladder but there is usually a
large vessel coming from the same side, but with the exception
of one specimen figured in Plate 2, .Fig. 4, which was
believed to be pathological, are not as numerous as shown by
Sappey.

In the subserous layer there is a network of lymph channels
which empty into these larger vessels. See Fig. 7. This
network is very irregular and the lymph channels vary mark-
edly in size and shape. The picture of these lymphatics
which seemed most normal was obtained by injecting carmine
gelatin into the portal vein at a pressure of 80 mm. of mer-
cury for fifteen minutes. This injects the lymphatics of the
liver and in turn the larger ones over the gall-bladder, and
finally these in the subserous coat in a more or less complete
manner, but without any tearing or stretching of the vessels.
In Fig. 2 they are represented as though the greater part
lie simply on top of the subserous layer, while, as a matter
of fact, they are scattered through it rather evenly.

The submucous sets of lymphatics are in the connective
tissue just under the mucous membrane. However, they
rarely run u]) into the connective-tissue folds but are at their
lowest part or more frequently just at their base. The net-
work is almost entirely absent in the denser muscular part.
These were best seen by injecting aqueous Prussian-blue
slowly under the mucous membrane and the injected portion
was afterwards fixed and studied. In some cleared specimens
the lymphatic vessels could be seen running up and joining
the more superficial lymphatics of the subserous layer or
directly one of the large superficial vessels as shown in
Fig. 1. The lymphatic tissue belonging to this layer has
already been described.

The nerve supply of the gall-bladder has been studied by
Dogiel (8) and Ilubor {'.)) within recent years. The nerve
supply is derived from two sources, viz., 1. tiie sympathetic
system of ganglia and fibres connecting them, and 2. raedul-
lated fibres accompanying the large arteries. In regard to
the distribution of the sympathetic fibres Huber suggests
from the condition prevailing in other viscera that they supply
the blood-vessels and smooth muscle of the coat. Doyon
thinks these are unable to act without receiving stimuli in-
directly from the great splanchnic nerve. Dogiel has figured
in a beautiful manner the kinds of cells found in the sympa-
thetic ganglia and concludes that all the varieties found in
the walls of the intestines occur here also. Quite a number
of medullated fibres are also found near the large arteries.
Both Huber and Dogiel have noted them. The former sug-
gests that they are sensory fibres and are distributed to the
mucous membrane. Their termination, however, has not
yet been settled by direct observation.

Eefehences.

(1) Rud. Virchow: " Ueber das Epithet dcr Gallenblase
imd tiber einen intermediaren Stoffwechsel des Fettes." Vir-
chow's Archiv, Bd. 11, H. 6, 1857.

(2) Wm. F. Hendrickson: "A study of the musculature
of the entire extrahepatic biliary system, including that of
the duodenal portion of the common bile-duct and of the
sphincter." The Johns Hopkins Hospital Bulletin, vol. ix,
1898.

(3) Maurice Doyon: "Etude analytique des organs mo-
teurs des voies biliares chez les vertebretes," These sc. nat.
Paris, 1894. An abstract of this article in Lehrbuch der
Vergleich. Mikros. Anat. der AVirbeltiere, Albert Oppol, Jena,
1900.

(4) K. K. Helly: " Die Schliessmuskulatur an den Miin-
dungen des Gallon und dcr Pankreasgiinge." Arch. f. Mikros.
Anat. Bd. 54, 1899.

(5) E. Oddi: " D'une disposition a sphincter speciale de
I'ouverture du canal choledoque." Arch. Ital. de biol. T. 8,
Fasc. 3.

(6) George Emerson Brewer: " Some observations upon
the surgical anatomy of the gall-bladder and ducts." Con-
tributions to the Science of Medicine by the Pupils of Wm.
II. Welch, 1900.

(7) C. Sappey: Description des vaisseaux ]yui]ihatiques.
Paris, 1885.

(8) A. S. Dogiel: Ueber den Ban der Ganglion in den
Geflecthen des Darmes und der Gallenblase des Menschen
und der Saiigethiere. Archiv f. Anat. u. Phys., 1899.

(9) G. Carl Huber: Observations on sensory nerve-fibres
in visceral nerves, and on their modes of terminating. Jour-
nal of Comparative Neurology, vol. x, No. 2, 1900.

DESCRIPTION OF PLATES XXV-X.XVI.

Fro. 1. — Tlio <!;[in-bUi(lder of a pig; natural size. Tlie lymphatics
were injected by placing the needle just under the peritoneal covering
of the liver near the edge of the gall-bladder at (.V). The blurred mass in
the centre represents the injection mass showing through and the

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXV.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXVI.

Fig. 4.

Fk:. h.

Fig. 6.

Fi(i.

Fig. S.

M. T. Suiller del.

Aphil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

129

lymphatic vessel coming up from the deeper layer to join tlie large
superficial one. X:= Needle of syringe.

Fig. 2. — Reconstruction of the wall of the partially contracted gall-
bladder of a dog, magniBed 60 times, showing the blood-vessels on the
right and the lymphatic vessels on the left. Lymph follicles are shown
on the right as two rounded eminences just under the epithelium. The
vena comites shown is quite characteristic for the larger arteries. The
large lymphatic vessel is shown partially collapsed.

Fio. 3. — Gall-bladder of adult man, showing superficial lymphatics.
}4 natural size.

F[G. 4. — Gall-bladder of man 19 years old, dead of chronic nephritis,
showing the large superficial lymphatics. This gall-bladder gave

evidence of having been through an inflammatory process, and so the
lymphatics are probably abnormally numerous.

Fig. 5. — Gall-bladder of dog, showing the superficial lympliutic ves-
sels. Natural size.

Fig. 6. — Section through the contracted gall-bladder of a dog, magnified
80 times, showing the arrangement into coats and the relations of the
blood-vessels.

Fig. 7. — The lymphatics of the subserous layer of a dog. (Camera
drawing.)

Fig. 8. — The lymphatics of the fibro-mnscnlar layer of a dog, showing
their relation to the folds on its surface. These folds are represented
narrower and less complicated than in the specimen in order not to hide
the lymphatics. (Outlines made with the aid of a camera.)

REMARKABLE CASES OF HEREDITARY ANCHYLOSES, OR ABSENCE OF VARIOUS PHALAN-
GEAL JOINTS, WITH DEFECTS OF THE LITTLE AND RING FINGERS.

By George Walker, M. D.,
Instructor in Surgery, Johns Hopkins Unircrsily.

Account.? of diverse abnormalities of the arms, forearms,
hands, and feet, are to be found in literattire from the re-
motest medical history, and not a few books and monographs
on these Yarious defects have appeared from time to time.
Most of these reports comprise instances of polydactylism of
various degrees; abnormal shapes of the metacarpal and
phalangeal bones; absence of the jihalanges and carpal bones;
increase in the number of the phalanges; absence of fingers;
absence of the bones in the arm and forearm; abnormal
sha]ies and lengths of the radius and ulna; lateral tminn of
the jihalanges; union of the fingers by the soft parts, etc.

Two cases have recently come to my knowledge which have
sufficient Ijearing on the ones herein reported to warrant a
short synopsis of them in this paper.

The first was that of a child in which there was a lateral
fusion of the first and second metacarpal bones of both feet.
This was not supposed to be hereditary until the grand-
mother, upon examining her own foot, to show where the
defect had occurred in the child, found her own bones in
exactly the same condition. Although she was seventy years
old, she had never previously noticed it.

The second case was that of a young girl whom I examined.
There was a partial stiffening in tlie metacarpo-phalangeal
articulation of the thumb; this was ligamentous, and not
bony, and permitted a certain amount of motion, probably
about one-half that of normal. This defect had occurred
in one of her brothers, one uncle, her father and her grand-
father. All of them were afl^icted in the same joint, and
had about the same amount of motion.

The cases which I herewith report show either a complete
bony ancliylosis or an absence of various Joints between the
l>halanges, together with an absence of one or more bones
of the little and ring fingers. As will be seen in the family
tree, it has occurred in five generations. I have examined
the cases so far as possible, and have made Koentgen photo-
gra]ihs from four of them, thus representing two generations.

Thomas B. applied to the dispensary of the Johns Hopkins

Hospital for the treatment of leg ulcer. He was fifty-two
years of age, well nourished and apparently well developed
and healthy. On examination of his hands I found the
thumb and index finger normal; in the ring and middle
fingers nothing could be seen on inspection in the extended
hand, contrary to the usual type, but on jialpation there was
found an entire bony anchylosis of the second metacarpal
joints of above fingers; the bony enlargements corresponding
to the heads of the bones were present, and in the middle
finger a distinct sulcus could be felt on the thumb side; other
than this the enlargement was regular and smooth.- The
terminal joints were negative. The little finger presented
only two phalanges, there being, however, near the end of the
first phalanx, a slight enlargement which possibly corre-
sponded to a joint. The thumb was 7 cm. in length; first
phalanx, 4 cm.; and second phalanx, 3 cm. The index finger,
8^ cm.; first phalanx, 3^ cm.; second, 3 cm.; third, 2^ cm.
Middle finger, 9:^ cm.; first and second together, 7^ cm.;
third, 1| cm. The first from basal joint to middle of enlarge-
ment, 4 cm.; the second, from middle of enlargement to distal
joint, 3i cm. Ring finger, 9 cm.; first and second phalanges,
6-^ cm.; third, 2^ cm. Little finger, 6 cm.; first phalanx, 3}
cm.; second, 2^ cm. The left hand presented nearly the
same appearance, and on cai'cful palpation and measurement
the only difference found was that in the little finger, first
phalanx, there was a slight bowing, making a palmar concavity
toward the end. This was due, according to the statement
of the patient, to an old fracture. Tlu^ enlargement at this
site, as is shown in Eoeutgen Photograph No. 1, is very much
greater than ift the other hand, and suggests that it had
probably i)een caused by trauma; in the other finger the
enlargement can be seen, but to a much less degree, thu??
making it doubtful whether there is an obliterated joint, or
the absence of the middle phalanx. The metacarpals were
of normal length and their articulations were negative. The
carpus was negative. The feet presented nothing abnormal,
except a slight giving way of the arch. The other parts of

130

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-133-123.

the osseous s_ystem were well developed and did not differ
from the usual types. The patient stated that the deformity
gave him very little inconvenience, and did not interfere
with his work. Both the above hands are shown in Eoentgen
Photograph No. 1.

On being questioned in regard to his family history, he said
that his father, grandfather and great-grandfather were simi-
larly affected. The middle joints of all his father's fingers
were stiff; the defect in the grandfather and great-grand-
father was known to have existed, but the e.xact nature could
not he determined. He had three uncles and one aunt; two
of the uncles he thought were affected, but was not certain;
the other uncle and aunt were free. In his immediate family
there were four brothers and one sister. One brother and
the sister had negative hands; the otber three brothers
])resented the family trait. He had four children, all of
whom were free. His younger brother had had three cliil-
dren, two dead and one living, none of whom were affected.
His elder brother had eleven children; four of them, two
boys and two girls, had the defect. I have visited and exam-
ined the two brothers and their families, and I give in the
following a report of said examination.

Henry B., the younger brother of the above described, is
a gardener, 48 years old; a strong, well built, healthy man;
five feet eight inches in height and weighs 148 pounds.
Both hands are affected. Right thumb, negative; length,
7 cm.; first phalanx, 4 cm.; second phalanx, 3 cm. Index
linger, length, G| cm.; first and second, 5 cm.; third. If
cm.; the first Joint is normal, second is stiff, distinct bony
enlargement at site of joint, slight sulcns on thumb side.
Middle finger, 2^ cm.; first and second phalanges, 7^ cm.;
third, 2 cm.; first from basal joint to middle of enlargement,
4^ cm.; first joint is negative, the second is stiff with rounded,
smooth, bony enlargement; no sulci. Ring finger, 8| cm.;
first and second, 6| cm.; third, 3 cm.; first joint is negative,
second anehylosed, bony enlargement not so marked. Little
finger, 5^ cm.; first and second, 3f cm.; third, 1^ cm.; the
first joint completely stiff, second negative, metacarpal bones
and carpus negative. Other hand presented same appearance
and nearly the same measurement. Feet and remainder of
bones in the body did not differ from normal.

William B., elder brother, very strong, hale, robust man,
58 years of age, 5 feet 11 inches in height, weighed 172
pounds. Both hands affected, as shown in Eoentgen Photo-
graph No. 2. Middle joint, ring and middle finger and both
joints in little finger stiff. Thumb and index finger normal,
remainder show absence of middle joints. Length of thumb,

7 cm.; first phalanx, 4i cm.; second phalanx, 2^ cm. Index.

8 cm.; first phalanx, 3| cm.; second, 3 cm.; and third, H cm.
Joints all negative. Middle finger, 9^- cm.; first and second
phalanges, 7i cm.; third, 2 cm. The first joint completely
anehylosed, distinct thickening at joint site, with small de-
pression. Ring finger, 9 cm.; first and second, 7 cm.; third,
2 cm.; first joint site presents nsual bony enlargement, but
no joint was present; second joint negative. Little finger,
5i cm.; slight palmar concavity, comjilcte anchylosis of lintli

joints; 1^ cm. from the end there is a slight enlargement
with furrow in middle at joint site, but no motion; the first
joint is also completely immobile. The metacarpals are nor-
mal in length, size and articulation; the carpus is negative.
The left hand does not differ in essential characteristics from
the one described. The feet presented no abnormality.

The patient stated that he had worked at the same bench
with two men for fifteen years, and they had never noticed
the defect. He had eleven children in his family, four of
whom were affected; the others had perfect hands.

I have seen most of the children of the above described,
and the following is the condition of the four wlio are affected.

Sallie B., aged seventeen, rather poorly developed, tall ami
slim, height five feet six inches, weight 115 pounds, both
hands affected, as shown in Roentgen Photograph No. 3.
Thumb and index, free; right hand, thumb, 6 cm.; first
phalanx, 3|- cm.; second phalanx, 2^ cm.; joint normal.
Index finger, 7 cm.; first phalanx, 3 cm.; second, 2| cm.';
third. If cm.; both joints negative. Middle finger, 8^ cm.;
first and second, 6| cm.; third, 2 cm.; complete anchylosis
fir.st joint, second joint is negative. Ring finger is repre-
sented only by the first plialanx, which is 4 cm. in lengtli.
The distal end is slightly enlarged, and tapers towards middle
finger. The little finger is represented also by only first
phalanx, 3| cm. in length. It presents same shape of enlarge-
ment at distal end as ring finger. The left hand is the same
as right, except that- the middle joint of the index finger is
anehylosed. In these hands, notably in the left one, there
is a distinct crowding together of the metacarpals, being most
marked in the fifth, which, as shown in the photograph,
decidedly overlaps the fourth. The carpi are negative; the
remainder of bones apparently normal. The feet were not
examined, but according to the statement of the patient they
presented no abnormalities.

Carrie B., aged fifteen, rather strong and robust, weight
one hundred and seventeen, five feet four inches in height.
I was unable to procure a photograph of this hand on account
of the unwillingness of the patient. Both hands are affected,
and very similar to those of her sister, as above described.
Right hand, thumb and index finger, normal. Ring and little
fingers of both hands, as in the case of her sister, present only
one phalanx, that of the ring finger is 4 cm. in length, and
that of the little, 3 cm.; the distal ends are slightly enlarged,
and according to palpation are like her sister's. In the other
hand the index finger is anehylosed at the middle joint, and
the middle finger presents a striking peculiarity in that the
anchylosis is in the second joint, the first being free.

Henry B., a picture of whose hand I was unable to obtain,
but upon examination found the following conditions:

Not very robiTst, tall and slim, age fifteen; height five feet
six inches, weight one hundred and twenty pounds, both hands
affected. Index and thumb in both negative, remainder
affected. Thumb, right, 5| cm.; first phalanx, 3 cm.; second
phalanx, 2| cm.; joint negative. Inde.x, 7| em.; first phalan.x,
3 em.; second, 2^ cm.; third, 2 cm.; phalanges normal in size,
and ioints negative. T\Tiddle finger, 8.', cm.; first and second

April-May-Junk, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

131

]ihalanges, 6^ cm.; third, 2^ cm.; first joint is stiff with dis-
tinct bony enlargement, and slight depression between heads
of bones; second joint is negative. Ring finger, 8 cm.; first
and second, 6 cm.; third, 2 cm.; first joint is anchylosed,
second is negative. Little finger, 5^ cm.; first phalanx, 4 cm.-,
middle is absent; the third, 1| cm. There seems to lie an
entire absence of the second phalanx; the first is normal and
presents no enlargement which might correspond to a joint.
The left hand differs in one particular from the above de-
scribed, in that the terminal phalanx of the little finger is
turned inward toward the ring finger, and forms an angle of
135 degrees with the second phalanx. The metacarpals and
carpi are negative. The remainder of the bones present no
defects.

George B., aged seventeen, height five feet six inches,
weight one hundred and fifteen jiounds, rather poorly de-
veloped, slightly anemic. J'>oth hands shown in Roentgen
Photograph No. 4. Right hand, thumb, G cm.; first phalanx.
'■Vj cm.; second, 2} cm., joint, normal. Index finger, 7 cm.;
first and second, 4^ cm.; third, 2^- cm.; first joint site shows
normal enlargement, but is stiff; second is negative. Middle
finger, 8 cm.; first and second, G cm.; third, 2 cm.; first joint
completely anchylosed; second, negative. Ring finger, TJ
cm.; first and second, 5-i cm.; third, 2 cm.; first joint stiff;
second, negative. Very slight enlargement at first joint site.
Little finger, 5 cm.; first, S^ cm.; second, absent; third, l-J- cm.
.Iiiint is negative; first phalanx is normal in length and shajK'.
(liei'e Ijeing no enlargement nor anything to suggest an anchy-
losed joint. Jletacarpals and carpi negative. The other
lianil [iresented the same apiiearance. The remainder of the
liiidy negative.

In ]ienising the literature bearing on these subjects, I have
round only a few similar cases reiioi'ted, none of them being
so marked as mine, and only one was hereditary.

Klausner, in a rather exhaustive monograph on various
deformities of the arm and band, reports a case in which the
anchylosis was present in the second phalangeal joint of the
index finger; the hand was very much deformed otherwise,
aiul the fingers partly webbed. There was no hereditary
history, nor were any other members of the family so affected.

Wolf, very recently, has put on record an anchylosis of the
second phalangeal joint of the little finger. In this case the
middle phalanx was very much shortened and was joined to
the first by a bony union at an angle of about 14.'J degrees.
The terminal phalanx was apparently normal. This anchy-
losis had occurred in four generations, and was in-esent in
eight instances. Some of them were inherited from the father
and others from the mother. The same joint of the same finger
was affected in every case; the remainder of the hand
was normal; there is no record of any other defects in the
body; the condition of the pectoral muscles is not mentioned.
The fingers in the cases of both Klausner and Wolf are shown
by Roentgen photographs.

E. Stintzing reports a case of a very much deformed hand
in which there was an almost complete anchylosis in the
second joint and partial in the first. In this case the fingers

were webbed; a diminution in the leUgth of several of the
nuddle phalanges and a defect in the right pectoralis major
muscle.

J. Sklovowski relates an instance of a defect of the sternum,
pectoralis major and minor muscles, and a portion of the
back muscles, together with an absence of the second, phalanx
in the second and third fingers; a shortening of the other
])halanges, and a limitation of movement in nearly all of the
phalangeal joints, with a complete anchylosis of both joints
in the fourth finger.

Hoffman describes a deformity occurring in a man 48
years of age, in which there was a stiffening in one or more
lihalangcal joints, and a shortening of the middle phalanx
of the middle finger. In the index finger the middle phalanx
was small and completely fused with the third [ibalanx.
There was also webbing of the finger?, associated with muscu-
lar defects in the chest and back muscles.

Fuerst gives an accurate account of a hand whieli was
examined after death by a very careful dissection. In this
hand there was great shortening and malformation of the
middle phalanx of the middle and ring fingers. There was
no anchylosis in any. In all of the above cases, with the
exception of the last, the observations have been made on
the living subject, and usimlly by palpation alone.

With the exception of the two girls in the ])resent genera-
tion of the cases which I herewith report, none of the
females have heretofore been affected, and in them appeared
the only instances in which the terminal phalanges were
absent. There is another striking difference in one of them,
as is shown in the Roentgen Photograph No. 2, in the partial
overlapping of the fifth metacarpal bone, which suggests the
)iossibility that continued transmission might produce a
fusion, or an absence of one of these bones.

From the above it will be seen that the defects have existi'd
in five generations, and have been confined entirely to the
hands, the i-eniaining osseous system pi-esenting no peculiar-
ities. Except in the )u-esent generation the hands have been
otherwise nornuil. The first dejiarture from this was in the
case of the boy. Roentgen Photograph No. 4, where there isau
absence of the middle phalanx of the little finger; while in
both of the girls, as is shown in one by the Roentgen Photo-
graph No. 3, the end and the middle phalanges of the middle
and ring fingers are absent. There is also a partial oblitera-
tion of the distal enlargement of the remaining phalanges.

By a study of the photographs, one can see that there is
undoubtedly a bony union and not a filn-ous anchylosis in
the joint sites. The enlargements corresponding to the heads
of the bones are plainly to be seen and felt, but the joints arc
absolutely unformed. In a number, small sulci could be pal-
pated, corresponding to the normal depression between the
heads of the bones. The jihotographs also show that there is
a certain porosity at the joint sites, which seems to be more
than normal.

The question arises whether these are cases of entire ab-
sence of the joints, or of early anchylosis. The two phalanges
are about the normal length, and there is a distinct enlarge-

132

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

uioiit coiTospoiuling to the metacarpiil lioads, with small sulci
between some of them, but other than this there is no evi-
dence whatever of an attempted Joint formation. In view
of the fact of a complete bony union, it appears best to con-
sider them as cases of an absence of the joint rather than of
an anchylosis. It has been suggested that probably the an-
cliylosis may have occurred after birth as the result of some
disease; but according to the statements of the motliers of
these various children, it was a congenital defect. A careful
examination of the other bones failed to show any abnormal
conditions or diseases, and the history of lues was not present.

The examination of the arm shows a fairly good muscular
development, and so far as could be made out there was no
atrophy of the flexor sublimis digitorum. The muscles of
the hand were also well developed and the thenar and the
hypothenar eminences were apparently normal. There was
an exception to this in the hand of the girls, where there was
found a rather poor development of the hand muscles, which
was most notably marked at the hypothenar eminence.

The palmar folds in the hand were normal, but in the skin
over the anehylosed joints they had become nearly smoothed
out; the two normal croasings being scarcely discernible.

The epiphyses were all joined; which was unfortunate as
otherwise some light might have been thrown on .the bony
development.

In nearly all of the reported cases there have been defects
in the back and breast muscles; the most striking examples
of which were found in the pectoral region. The cases which
I herewith report presented no such abnormality, and showed
upon examination a completely developed condition of the
muscles of the arm, shoulder and back. In all the instances
the feet were negative.

These cases are in striking contrast to the generally ac-
cepted opinion that deformities of the hands and feet arc
transmitted by the mother, for in each of those in this
series it came through the father, the mothers having all
been normal. It is most interesting to note that in each
generation only one male member has transmitted the de-
formity to his offspring.

The occupations of tlic individuals were very little inter-
fered with; the only inability complained of was that of
being unable to grasp small articles with the whole hand.
The deformity, except in the cases of the two girls, was not
at all striking, and unless one carefully inspected the hands
it would be overlooked, and even in shaking hands it was not
noticeable.

Shortening of the Phalanges.

In my cases, as well as in most of the above-reported ones.
there has been a decided shortening of one or more of tlic
phalanges. It has been in nearly every instance most stiik-
ingly observed in the middle phalanx with a certain predilec-
tion for the little finger.

In discussing such cases, Fuerst states that in nearly all
of these defects the shortening is seen in the middle phalanx.
and he ascriljes it to the fact that in embryologic develop-
ment the middle phalanx is the last to become bony. This

occurs when the embryo is about 8 centimeters in lengtli.
and he thinks that at this period the deformity commences.
From observations of his case, and a study of certain others,
he concludes tluit the shortening and anchylosis are stages in
fusion of the first ajid second bones. The shortening repre-
sents the first stage; the anchylosis the second stage, and the
whole phalanx the third stage.

Tliis theory does not seem to be based upon sufficient obser-
vation, nor is there enough evidence in the studied cases to
justify any such assumption.

In my cases, as is shown in tbc photograjihs, there is no
shortening at all in the ]ihalanges of the second and third
fingers, although a com])lete anchylosis exists; this would
stand directly against the theory which Fuerst has advanced.
In the little finger, however, there is some evidence for the
liypothcsis, for in the second generation there is present a
diminution in the phalanx, then an anchylosis, and finally,
in the case of the boy, the joint has entirely disappeared,
and there remain only two normal phalanges.

A very distinct and decidedly unique type, so far as the
above-mentioned cases are concerned, is to be seen in the
hand of the girl; for in this case the end and middle phalanges
have entirely disappeared, and have left the first phalanx
only partially developed. The diminution and absence of
the end phalanx were not noted in the other reported cases,
and can not be explained on the ground of the late bony
development.

The little finger first shows a beginning defect, and in the
case of Thomas B., Eocntgen Photogi'aph No. 1, left hand,
the first phalanx is long, somewhat curved, and presents a
slight enlargement which probably corresponds to a joint
site. The middle phalanx then will be represented by a
small bone about H cm. in length. In the case of the
nephew there are certainly only two phalanges; and in each
of the girls only one is present, and the defect has extended
to the ring finger.

Thanks are due to Dr. Finney for ]iermi.ssion to re])iirt
these cases. I am also indebted to Professor W. A. S. Ham-
UK^l for the care which he gave to the preparation of the
photographs.

Literature.

Wolf: Ifucnchener niedicinische Wochenschrift, Mai '21),
1900, No. 22.

R. Stintzing: Dcr angeborene und crworbene Defect dcr
Rrustmuskeln, zugleich ein klinischcr Beitrag zur progrcs-
sivcn Muskelatrophie. Deutsches Archiv fiir klinische Mcdi-
cin, 15 Bd., 1889.

J. Sklodowski: ITebcr cineu Fall vtm angeborencin
I'echtsseitigem Mangel der M. pectoralis major et minor uiit
gleichzeitigen Missbildungcn der rechtcn Hand. Archiv ftti-
path. Anat., etc., von E. Virchow, Bd. 121, 1890, 1.

Hoffman: Ein Fall von angeborenem Brustmuskeldefect
niit Atrophic des Amies und Schwimmhautbildung. Vir-
chow's Archiv, Bd. IIH, 189fi, S. 163.

Fuerst: Zeitschrift fiir Morphologic und Anthropologic.
Band II, Heft 1, 1900.

THE JOHNS HOPKINS HOSPITAL BULLETIN. APRIL-MAY-JUNE, 1901.

PLATE XXVII.

Fig. 1.

Fig. 2.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXVIII.

Fig. :!.

Fio. i.

April-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

133

Thomas B.,
Known to be aflectt-d.

Charles B., son.

Known to be utt'ected.

Exact condition unknown.

Charles B., (iraudsuu.
Unknown.

John B., Grandson.

Both hands, middle joint,

all tinners.

Susan B.,

Granddaughter.

UnalTected.

C'HAiiLES B., Grandson.
Unknown.

William B.,

Great-trrandson : Both hands,
rintt, middle and little lingers.
First joint.

Sallie B., I

Great-jrreat-granddaui; liter.
Both hands, inde.x and middle
linger. King and little linger,
one i)halan.\ only.

Carkie B.,

(i reat-great-granddaughter.
Both hands; middle linger, tirst
and second joint, right hand.
Iude.\ and middle, Urst joint,
left hand. Ring and little
linger, one phalanx.

George B.,

Great-great-grandson.
Botli hands, inde.x, ring and
middle fingei, first joint;
:ihsenee phalanx middle linger.

Henry B,,
Great-great-grandsou.
lioth hands, ring, middle and
little linger, tirst joint.

Joseph B.,
UnalTected.

Caleb B.,
Unallected.

Edith B.,
Unatl'ected.

George B.,
Unaffected.

JOSEI'II B.,

Unaffected.

Susan B.,
Unaffected.

Charles B.,
Unaffected.

Thomas B,,

Great-grandson.

Both hands, ring,

middle and little linger.

Middle joint.

Jennie B.,
Unaffected.

Marv B.,
Unaffected.

John B.,
Unaffected.

William B.,

Unaffected.

Henry B.,
Great-grandson. Both
hands, middle and ring
linger. Middle joint.

Charles B.,
Unaffected.

Joseph B.,
Unaffected.

Margaret B.,
Unaffected.

JacoI! B.,
Unaffected.

Cora B ,

Unaffected.

NOTE ON THE BASEMENT MEMBRANES OF THE TUBULES OF THE KIDNEY.

By Kr.vnki.in P. M-\ll.
Professor of Analomij, Johns Hopkins Universily.

In au earlier jmMication upon reticulated t).«sues in general
tlie statement wns made that the whole framework of tlie
kidney, including the lja.sement membranes, from the capsule
to the pelvis, is formed by one mass of anastomosing fibrils,
and that the sliarp borders of the librils mark the outlines

of the tubules to form the basement membranes which in
ordinary sections i!]ipear to be homogeneous.' This state-
ment was based upon observations made by digesting frozen

' Mall, Abhandl. dcr math.-phys. classe dcr Kiiiiigl. Siicli. (iesehell. der
wisscusch., Bd. Ill, and Johns Iloiikius Hospital Reports, vol. 1.

134

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

sections of the kidney, digested in pancreatin, stained with
acid fuchsin and differentiated with picric acid. By this
method all of the cells and other structnres of the kidney
are destroyed, leaving only the white fibres and reticulated
fibrils which are stained intensely red. This observation has
been confirmed by Eiihle," who used a method similar to the
one I employed. Eiihle digested small blocks of kidney (after
hardening in alcohol) with pancreatin until all the cells were
dissolved, then made sections in paraffin, which were stained
irpon the slide. By this method the topography of the
reticulum is retained much better than is the case in spec-
imens made by the freezing method.

Fig. 1. — Lousitiidinal section of the fr.imewoik encircling a kidney
tubule digested in pancreatin, stained witli acid fuchsin, and differentiated
with picric acid. Enlarged 'SiS times.

The work of Eiihle, which is very accurate and extensive,
shows quite conclusively that the fibrils obtained by his
method, as well as by the freezing method, are identical with
those which form the interstitial tissue as seen in ordinary
sections.

The observations given above have been confirmed by
Disse,' who states, however, that the basement membranes of
the kidney which have been isolated by means of strong acids
always appear to be homogeneous. This he explains by as-
.suming that pancreatic digestion resolves the membrane into
fibrils by dissolving the cement substance between them.
The strong acids, however, dissolve the interstitial connective

tissue but do not affect those fibrils which are stuck together
by the cement substance to form basement membranes.

Von Ebner' is of the opinion that the iibrillar a])pearance
of the basement membranes of the kidney is due to fine folds
in it owing to the method of preparation. He further states
that the fibrils of connective tissue between the tubules stain
with acid fuchsin while the membranes do not. There is
some truth in this statement, for in sections of the kidney
which have been macerated and slightly tinged the stained
fibres shine through the homogeneous membrane, often mak-
ing it ajipcar folded. Yet with some care the true nature of
these makings is easily determined.

-lUihle, His's. Archiv, iS'.l".

3 Disse, Sitzungsbericlite dcr Gescliellsch. zur Beforderung der ge-
sanimten Naturwisseuschaftcn zu Marburg, November, 1898.

Fig. :.'.— Transverse section of the rcticulura encircling a kidney
tubule prepared as Fig. 1.

Keceiilly, while studying sections of the fresh kidney liy
m{>ans of various methods, I obtained specimens which ]n-oved
that tlie ol)servations of Eiihle, Disse and myself are correct,
so far as they go, but that our conclusions regarding the
basement membranes are not correct. The baskets, which I
reproduce in Figs. 1 and 2, do exist, are easily obtained by
means of pancreatic digestion, but do not form the basement
membranes. An additional membrane, the basement mem-
brane, lies within this tube and is totally destroyed by means
of pancreatic digestion. The most instructive specimens I
obtained were made by macerating frozen sections of the
rabbit's kidney in a cold saturated solution of bicarbonate of
soda for a number of days, after which most of the cells have
been converted into a slimy mass. Shaking the section vig-
orously in water soon cleared the framework, wliicli was next
spread upon a slide and examined. In case most of the cell
remnants had been removed the section was dried upon the
slide, stained with acid fuchsin, differentiated with picric

■• Von Ebner, Kolliker's Handbuch der Gewebelehre, Bd. 3, S. 374-375.

April-May-JuxNU, IIJOI.J

JOHNS HOPKINS HOSPITAL liULLETIN.

135

acid and numiite'd in halsani. Suceossful sections prepared
in this way sliow the basement membranes partly filled with
the remnants of epithelial cells, the interstitial reticidatcd
connective tissue and the blood-vessels. A portion of such a
specimen is shown in Fig. 3.

After specimens of the basement membranes and the rctic-
uhim are obtained through maceration in bicarbonate of soda,
as described aliove, they may be treated with various reagents
to test their projierties. Dilute solutions of IICl and KOI I
cause the reticulum to swell and become transparent, whili'
the basement mendjrane and the elastic filjrils accompanying
the arteries remain unchanged. But it is shown by the
Weigert's elastic tissue stain that the mem])ranes are not
elastic, for they do not take on the stain wliile the elastic
tissue fibres do. Furthermore, Mallory's connective tissue
stain,° stains the reticulum but not the membranes. As far
as I have tested the basement membranes they give reactions

^ Mallory, Journal of Exitcriniental Mi'tliciiiu, vol.

much like the membranes of elastic fibres, but whether they
arc identical with them I have been unable to determine.

Fig. 3. Lon</;itu(linal section of a kidney tubule with the surrouudinK

reticulum from a specimen macerated in bicarbonate of soda for a week,
shaken, dried upon the slide, stained with acid fuchsiu and dill'erentiated
with picric acid. The basement membrane partly tilled with broken
epithelial cells and surrounded with reticulum are shown. The drawing-
is semidiaijrammatic.

A COMPARATIVE STUDY OF THE DEVELOPMENT OF THE GENERATIVE TRACT

IN TERMITES/

By H. McK. Kxower, Ph.D.,
Inslrnclor in Anaioniij. Johns Hopkins Univcrsiiij.

Tiie facts here prescnled furnish a mure accurate guide in
estimating the status of individuals in the communit} Hum
has been hitherto available. Xew light is thrown on hypo-
theses as to the possible inlluence of workers and soldiers in
the transmission of hereditary characters in these communi-
ties. These studies will also be seen to bear on jiroblems of
the comparative morphology of the sexual organs of insects.
Six species of two genera (Calotermcs and Termes) were
investigated.

The efferent passages and accessory glands of Termites
are simple, as in Thysanura. In Termes flavipes they
arise first in larvs just hatched, in which the mesodermic
duct from ovary or testis ends blindly against the ectoderm
of the hypodermis. In the female three separate and seg-
mental, unpaired invaginations of the ectoderm appear, one
behind another on the ventral mid-line. The pouch of the
anterior segment comes into contact with the mesodermic
oviducts, that of the next segment later becomes the recep-
taculum seminis, while the posterior invagination bifurcates
at its inner end and eventually forms the colleterial glands.
In larva? preceding those evidently destined to become work-
ers and soldiers, and in adult workers and soldiers, this dis-
connected segmental condition persists (Fig. 1). In other
word.s, the workers and soldiers exhibit a peculiar arrested,

' A preliminary abstract presented to the American Morphological
Society, December, lUOO.

larval stage in the dcvelopmcul u£ the sexual ap|iaraUis. In
older larvaB of sexual individuals the three, segmental, inde-
pendent rudiments telescope together and unite to form a
vaginal canal with colleterial glands, reccptaculum seminis,
and mesodermic oviducts opening into it. In the male there

Ov.il.j-ct.

Rectft. 5e«>.
c:<.U.slo«A.

Fio. 1. — Modilied camera sketch of ventral aspect of tip of abdomen
of Termes flavipes, adult worker or soldier. Female.

is a single median ectoderinic invagination into which the
j)aired, mesodermic vesicuhe semiuales, and vasa deferentia,
eventually open (Fig. 2). In adult workers and soldiers of
this sex an arrested larval type is exhibited in the sexual
apparatus.

Modifications of this history occur in i)tlier siiecies, affect-
ing workers and soldiers especially.

136

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nog. 131-123-123.

In a species of Eutermes from Jamaica the most extreme
inodiflcation is found. Not even rudiments of the cctodermic
passage and accessory glands a])pear in Avorlscrs or soldiers
(Nasuti) of this species. The origin of the ectodermic ap-
paratus of sexual individuals of this species is, however,
essentially that of the corresponding structures of flavipes.

SfiUicU.

Fig. 3. — Similar sketch of adult worker or soldier. Male.

The condition of the mesodermic sexual gonads, male and
female, is very simjjle in a Jamaican species of Calotermes, a
primitive genus of the group. In advanced larvae and in
soldiers the ovary is a series of egg-tubes opening into the

oviducts, while the testis is composed of the same number
of tulmles or follicles arranged serially on the vas deferens.

In T. flavipes and in the Jamaican Eutennes the youngest
larvffi exhibit a condition similar to that in Calotermes, which
arrangement, it will be observed, Ijears a suggestive resem-
blance to the type found in Thysanura.

In the Jamaican Eutermes the workers and soldiers exhibit
an extreme arrest of the development of the gonads, which
do not proceed beyond the stage found in the youngest larva
just hatched.

The adult workers and soldiers of a Japanese species of
Termes. unlike T. flavipes, possess gonads not greatly modi-
fied from the serial type which seems to be primitive.

In T. flavipes the gonads of older larvre and of adult
workers and soldiers in both sexes lose this priinitive type:
the tubules of the testicle, for instance, becoming twisted
into a globular mass in which the original serial order is
obscured.

The gonads of larvae of sexual individuals, in all species
studied, change from the condition at hatching to a type in
which the simpler original arrangement is much obscured.

Additional facts with suitable discussions will be published
shortly, fully illustrated.

A COMPOSITE STUDY OF THE AXILLARY ARTERY IN MAN.

By J. M. HiTZEOT.

{From the Anaiotnli'al Lahorotory of the Johns Hopkins University.)

At the suggestion of Dr. Mall the following records were
made from dissections in the Anatomical Laboratory of the
Johns Hopkins University during 1898-99 and 1899-1900.
Charts' were furnished the students with the request that
they draw the axillary artery with its branches, etc., as found
in their subjects, giving as nearly as possible the origin and
distribution of each branch and maintaining the relation to
the pectoralis minor and the various bony structures of the
axillary region. The charts were merely outlines of the
skeleton upon which each student sketched his dissection.
When this sketch was finished it was added to or changed Ijy
the writer, so that the sketch might, as nearly as jiossible,
represent the artery as it existed in each dissection. Parallel
with these drawings a set of not€s was kept in which the
constant and the unusual branches of the artery were care-
fully noted. During the year 1898-99, considerable difficulty
was experienced with the terms short thoracic, acromio-thor-
acic, etc., the student in his eagerness to apply these terms to
the different branches often overlooking the more important
feature, i. e., the distribution of the branch. To obviate this
to some extent the charts of this year were compiled and the
composite picture thus obtained was drawn and furnished as
a guide for the future. The terms before mentioned were
kept but special stress was laid upon the origin and distribu-

1 Bardeen, Outline Record Charts used in the Anatomical Laboratory
of the Johns Hopkins University, Johns Hopkins Press, Baltimore, 1900.

tion of the artery. The results thus obtained were uniformly
more satisfactory than those of the previous year.

The charts used in the following tabulations are less than
a third of the total number made. The remainder, because
of errors in drawing, broken arteries in dissecting, and dis-
crepancies between the notes of the writer and the sketches,
were omitted. These omitted charts, in so far as they were
of any value, gave jiractically the same results as were ob-
tained from the tabulation of the coiTcct and more complete
charts. In making the tabulations the arbitrary divisions
given by the various anatomists were used.

Part I, that portion of the artery extending fi(nn the
lower border of the first rib to the ujiper border of the
]iectoralis minor.

Part II, that portion of the artery which is beneath the
pectoralis minor.

Part III, that portion of the artery which extends from
the lower border of the pectoralis minor to the lower border
of the tendons of the teres major and latissimus dorsi.

During the first tabulation separate tables were made for
the right and left sides to determine whether the origin and
distribution differed on the two sides. As the only dift'erence
found was in the presence or absence of the long thoracic
artery this distinction was dropped, the relative dift'erence
consisting in the more constant presence of the long thoracic
artery on the left side.

Apeii^May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

137

The charts themselves conveniently fall into different types,
that i.-;. the artery in a certain number of instances gives oif
its lij'anches from the same divisions of tlie arterial trunk and
these brandies are distributed to tlie same regions. The ti'
charts here taimlated fall into 7 types, type I being present
in 20 cases; type II in 9 casjs; type III in 7 cases; type IV
in 4 cases; type V in 3 cases; and tyi>es VI, VII each in 2
cases.

Type I (Fig. 1 and Table I).

This type, the most constant found in the laboratory during
the two years the dissections were observed, differs from the
text-book descriptions by the absence of the long thoracic
artery. The area ordinarily supplied by this artery, accord-

FiG. 1. — Type I of the axillary artery. Present 30 times in 47 cases.

.1, Ramus acromialis ; a, Ramus ascendens; AC, A. circumflexa
humeri anterior; b, M. biceps; C, R. clavicularis ; eb, M. coraco-brach-
ialis; D, M. deltoideus; <l, Ramus anastomotieus; DH, A. eireumflexa,
scapukr, (dorsal scapular); LB, il. latissimus dorsi; P, R. pectoralis;
PC, A. circumtlexa humeri posterioris; PM, M. pectoralis major; pm,
M. pectoralis minor; .S', A. subscapularis ; s, M. subscapularis; SM,
M. Serratus anterior (magnns); .S'P, A. profunda bracliii, (superior
profunda); T\ A. thoracalis suprema ; T-, A. thoraco-acromialis ; T ■',
A. thoracalis lateralis; TM, M. teres major; 1, 2, 3, 4, 5, 1st, 3d, 3d,
4th and .5th intercostal spaces.

ing to te.vt-books, being supplied by liranches from the
acromio-thoracic and subscapular arteries. The branches in
this type can be conveniently arranged in the following
schema: I

( 1. Superior thoracic.

Part 1.

Part II.

Part III.

Acromio-thoracic.

No branches.
1. Subscapular.

(■ 1. Thoracic branch.

I 3. Acromio-hnmeral branch.
l_ 3. Clavicular.

C 1. Dorsal scapular.

I 3. Muscular branches.

] 3. Anterior.

[ 4. Posterior.

., , . . . „ ( Ascending branch.

3. Anterior circumflex. .; , . ",.
( Anastomotic.

o. Posterior circumflex.
4. Muscular branches.

( Muscular.
\ Anastomotic.

iCoraeo-brachialis.
Biceps.

The superior thoracic (A. thoracalis suprema) rises just
below subclavius muscle and crosses the first inters]iace, end-
ing in it and in the second interspace. The origin of the
artery is remarkalily constant in this type (19 times in 20
cases), it supjilies the muscles in the first and second inter-
spaces.

The acromio-thoracic (A. thoraco-acromialis) rises from
Part I. about midway between the clavicle and upper border
of the pectoralis minor, runs almost directly anteriorly and
divides into the (1) thoracic branch, (2) the acromio-humeral
and (3) clavicular branch.

This artery is the most constant in this type, being present
in ail 20 cases. The thoracic branch turns downward beneatli
the pectoralis minor, giving off branch to the pectoralis major
and minor, and to the second and third intercostal spaces and
the overlying skin. The acromio-humeral branch runs up-
ward and outward across the costo-coracoid membrane over
the coracoid process of the scapula and gives a branch to the
acromion and accompanying the cejihalic vein between the
deltoid and pectoralis major breaks into branches, supplying
these two muscles and the snrnuinding fascia and skin. The
clavicular branch is a small branch which turns upward to
sujiply the subclavius muscle.

Tlie subscapular artery arises from the axillary trunk at
the lower border of the subscapularis muscle and takes a
downward and inward course through the axilla. Near its
origin it gives off a branch to the subscapular muscle and a
large branch, the dorsal scajiular, which passes through the
triangular space formed iiy the subsca]iularis, teres major and
long head of the triceps, to the dorsum of the scapula, sup-
]ilying the muscles of that region. A small branch to the
teres major muscle then comes from the subscapular trunk
as it crosses that miscle, and before it splits into the thoracic
iir anterior branch and its posterior or muscular branch. The
thoracic branch crosses the base of the axilla from the back
to the front and supplies the serratus magnus, the fourth and
fifth interspaces, and the adjacent skin. The posterior
branch continues the downward and backward course of the
subscapular trunk tn end in the serratus magnus, and the
latissimus dorsi, giving off numerous branches to these
muscles.

Two small muscle branches are given oft' to the coraco-
brachialis and biceps.

From the anterior portion of the axillai'y trunk a small
artery, the anterior circumflex, rises, passes beneath the
coraco-brachialis aJid biceps and sends a branch to the joint
by way of the bicipital groove and a branch around the arm to
anastomose with the posterior circumflex artery. In its
course it gives otf brandies to the overlying muscles. At
aiiout the same level and from the posterior portion of the
axillary artery the posterior circumflex takes its origin,
passes downward and backward through the space bounded
by the teres minor, long head of the triceps, teres major and
the humerus, winds around the neck of the humerus, supply-
ing the deltoid, the joint, the triceps, and the adjacent skin

138

JOHNS HOPKINS HOSPITAL BULLETIN.

[No.s. 121-123-123.

;iml anastomoses with the anturior circumflex artery and
bufierior profunda artery.

Type II (Fig. 3 and Table II).

Tlie braiulics in type II are conveniently arranged accord-
ing to the following plan:

C Superior tlioracic.

Parti.

] Acromio-tluiracic.

Part II. j Long tboracic.

!1. Thoracic braucli.
2. Acromio-lnimeral 1
o. Clavicular braucli.

branch.

Part III.

Subscapular.

C 1. Dorsal scapular.
I 2. Muscular branches.

1^ 3. Posterior branch.

». , ( Anterior circumtlex.
Trunk. - „ , • • „

^ Posterior eircumfle.x.

This type ditl'er.'; fmni tyiie 1 only by the presence of a
branch from the part II of the axillary trunk and corresponds

Fig. 3. — Type II of the axillary artery. Present '.) times in 47 cases.

with the description of the axillary artery usually given in
the text-books. This branch from the second part of the
artery bears the name long thoracic (A. thoracalis lateralis).
It takes its origin beneath the pectoralis minor, courses down-
ward along the lower border of this muscle, supplying it, the
serratus magnus, and the third, fourth and fifth interspaces.
In its course it gives off small branches to the fascia of the
axilla, and terminal branches which piercing the pectoralis
major terminate in the overlying skin. The other arterial
branches have the same origin and distribution as described
in type I, except that the intercostal areas of the thoracic
branch of the acromio-thoracic artery and the thoracic branch
of the subscajnilar artery are replaced wholly or in part by
this branch from part II. The anterior and posterior cir-
cumflex arteries arise by a common trunk but otherwise their
course and distribution correspond to the description gi-ven
under type I.

Type 111 (Fig. 3 and Tai;le III).

Part I.

f Superior thorjicic

! .\cromio-th'_'racic.

Thoracic br.
A croniio- humeral.
Clavicular.
C I. Thoracic branch.
I 3. Muscular branches.
I H. Posterior circumflex.
"j 4. Dorsales scapulae.
I r>. Anterior branch.
[ G. Posterior "
( Ascending.
.\nterior circumflex. I

( Anastomotic.

Part II. Subscapular

Part III

The branches from part I are similar in their origin and
distribution to those described in type I. From part II a
large subscajnilar artery takes its origin. It immediately
gives off a l)ranch (tlioracic) which supplies the serratus
magnus and crossing the axilla licmeath the pectoralis minor

Fig.

-Type III of the axillary artery. Present 7 times in 47 cases.

supplies that muscle and the second, third and fourth inter-
spaces. Just above the lower border of the pectoralis minor
a larger branch descends which gives off the posterior cir-
cumflex dorsal scapular, and muscular branches and termi-
nates in an anterior branch to the fifth interspace and serratus
and a posterior branch to latissimus dorsi and serratus. From
the drawing and description the thoracic branch of this
artery can be seen to correspond with the description of the
" long thoracic " artery, while the lower descending branch
corresponds to the description usually allotted to the sub-
scapular artery. The artery, however, can lie Ijetter de-
scriljed as the subscapular artery because, as is seen in type I,
the subscapular artery does supply the mid-thoracic region
and because the long thoracic artery is so often absent. The
anterior circumflex has the same origin and distribution as
that given it under type I.

Apeil-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

139

Type IV (Fig. 1 axd Table IV).

In type IV the aeromio-thoracic artery commonly fonnd in
part I is foimd arising from part II of the axillary trnnk.
The distribiition of the branches in this type is similar to
that given nndor type I (the snperior thoracic supplying the

Fig. 4. — Type IV of tlie axillary artury. Present 4 times in 47 cases.

first interspace only), with an added lirancli to the subseapn-
laris mnscle which, taking its origin from part I, turns back-
ward and downward, passes between the trunks of the brachial
plexus and ends in the subscapularis muscle.

( Superior thoracic.
Part I. )

( Braneli to M. subscapularis
f Tboi'aci

Part II. Aeromio-thoracic. '

i Clavicular.
I Acromio-bunieral. ^ Acromial.
(^ ( Muscular.

C ., , , , ( Coraco-bracliialis.

I Muscular branch. - „.

( Bleeps.

I pi. Muscular.

T, , „, ' , , , I 2. Dorsal scapular.

Part III. -; Subscapular. >,.,,,■

'^ ' 3. Anterior.

[_ 4. Posterior.

„ , ( Anterior circumllex.
i Trunk. < r, , •
[ (Posterior "

Type V (Fig. 5 and Table V).

From the table aud drawing it is readily seen that prac-
tically the wliole jiectoral area, the thoracic and subscapular
regions, are supplied by an artery given off from part II of
the axillary artery. From the table it will be noticed that
this was the case twice, while in the third case two arteries
with the same distribution as the above mentioned trunk
have separate origins from the main trunk. In this latter
case the origins of the two arteries supplying this whole area
were so close together that for practical purposes they can
bo called a common trunk and are incorporated as such in
the drawing of tin's type. It is important, however, to re-

member that type V may be represented by two branches
rising close together from part II, as is seen by the drawing
given for that type. In one ease the trunk had an even
larger area of distribution than is shown in the drawing, the
anterior and posterior circumflex regions being supplied by

3—

Fig. 5. — Type V of tlie axillary artery. Present "• tinics'iu 47 cases.

branches from the large trunk from part II. These two
variations in type V are given because future research may
show that one of these variations is more common than that
found to be most frequent in my observations.

Part I.

Part II.

I Superior thoracic (small).

f c Thoracic branch.

. . ■ .1 • ! . ■ ( Clavicular.

1. Acromio-thoracic. J Acromio- \ . . ,

, , J. Acromial,

humeral. 1 .,
[ ( Muscular.

2. Long thoracic.

[' Muscular.

., „ , , I Dorsal scapular.

i. subscapular. ■ . , • . ■

] Anterior branch.

[_ Posterior "
Anterior circumflex.

Part III.

( Anterior
( Posterio

In the above schema I have called the branches by their
adopted names, and the distribution of each branch from this
trunk is similar to the distribution described under types
I and II.

Type VI (Fig. G and Table VI).

This type existed but twice in the dissections observed and
is remarkable for the number of branches wliicli ari.'^e from
part I.

Part I.

f Superior thoracic.
Aeromio-thoracic.

I Pectoral branch.
Long tlioracic.

{Clavicular.
Acromial.
Deltoid.
( Muscular.
( Intercostal.

140

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

Part II. No branches, f Dorsal scapular.

r „ , , I Muscular.

Subscapular -(..., ,

I ^ ' Anterior branch.

,,. J l_ Posterior "

Part

j Trunk.

f Anterior circumflex.
\ Posterior "

The superior thoracic is small, giving a twig to the upper
digitations of the serratus and ends in the first interspace.

Fig. 6. — Type VI of the axillary artery. Present '2 times in 47 cases.

TIlis type shows to a marked degree a variation which occurs
in the origin of the acroniio-thoracic artery, i. e. a separate
origin of its pectoral or tlioracie branch, while the artery
designated as the acromio-thoracic is merely the acromio-huni-
eral division of that artery. From the table it will be noticed
(line 2, table VI) that tlie thoracic branch of the acromio-
thoracic artery was ]n-eseut in one case. My notes on this
case mention the fact tliat this branch was extremely small
and that the area usually completely supplied by it receives
most of its blood-supply from a branch rising from the main
trunk. This pectoral branch rises from the trunk slightly
above or just adjacent to the origin of the acromio-thoracic
artery, courses downward and forward, supplying the pec-
toralis major and minor and the second, third and fourth
intercostal spaces. The long thoracic artery, except for its
origin, is similar to that described under type II.

The subscapular artery is the same as that of type I, and
the trunk common to anterior and posterior circumflex ar-
teries is the same as that of type II.

Type VII (Fig. 7 and Tablk VII).

Type VII occurred but twice in the records made. In this
type, as in type VI, the thoracic branch of the acromio-
humeral artery is very small, being represented by a small
twig to the pectoralis minor, while its area of distribution is
supplied by a branch from the large subscapular artery; in
type VI it was supplied by a separate branch from the axil-
lary trunk.

[■ Acromio-thoracic.

Part I.

Part II.

Thoracic.

Clavicular.

Acromio-humeral.

Acromial.
Muscular.

Pectoral.

Subscapular.

No branches.

j Upper division,
j Lower "
■{ Muscular.
! Dorsal scapular.

Anterior division.
1 Posterior '*

1 >.

F:q. 7. — Type VII of the axillary artery. Present 2 times in 47 cases.

Part III. Trunlc.

C Muscular branch.

„ , ( Anterior circumflex.
■^ Trunk.

( Posterior
Superior profunda.

In this type the superior thdracic is absent and its area
of distrilnition is supplied by the suliscapular.

The cromio-thoracic is the same as type 1; while the thor-
acic or pectoral branch is small. The subscapular arises well
above the upper border of the pectoralis minor, turns down-
ward beneath that muscle and supplies the whole thoracic,
pectoral and subscapular regions. Part III gives off a large
trunk which runs parallel to the main artery, gives off
branches to the eoraco-brachialis and biceps, and a trunk
wliich immediately splits to form the anterior and posterior
oircumtiex arteries (distribution similar to that under type I),
and then turning down, out and back passes through the
musculo-spiral groove to become the superior profunda artery.

In the first part of this paper the types into which the
axillary artery fell are discussed and it is my intention in
this portion to discuss the individual branches with their
origin, distribution and variations.

Superior Thoracic. — This artery was remarkably constant,
appearing 40 times in the 47 cases here tabulated. In the
7 cases in which it was absent it was supjilied by the acromio-
thoracic in 4 cases. This is the condition described as normal
by Testut, Sappey and Cruveilhier. In 2 cases the subscapular
supplied its area (type III), and in one case a large trunk
from paxt II of the axillary (type V). The artery was most
frequently distributed to the first and second interspaces,

Aphil-May-Jdne, 1901. J

JOHNS HOPKINS HOSPITAL BULLETIN.

141

as in type I. In 4 cases, however, the artery was distinctly
longer than normal and rising high up in the axilla, turned
directly downward and passed along the lateral thoracic
wall, supplying the interspaces from 1 to 4 (in 2 cases the
5th also) and the serratus magnus muscle. This artery was
in close relation to the posterior thoracic nerve, heing anterior
to it and separated from it by an accompanying vein. As
far as can he ascertained, this artery has not been described
before. In one of these cases the artery was of considerable
size and gave branches to the glandular contents of the
axilla and sent numerous branches forward in the intercostal
spaces. In some respects it corresponds to the long thoracic,
hut owing to its presence in a case in which the long thoracic
was present also, and its origin near that ascribed to the
superior thoracic, it has been included in the description of
the superior thoracic artery.

Acromio-tlwracic Artery. — This branch, the most constant
of the axillary subdivisions, came from part I in 40 cases,
from part II in 5 cases and in the remaining 2 cases came
from the trunk common to it, the subscapular and long
thoracic arteries (type V). For convenience of description
the following schema of the acromio-thoracic artery will be
found very useful.

Acromio-thorac

J Pectoral brai

ic. } Clavicular bi

^ Acromio-huE

Pectoral branch,
branch,
imeral brauch.

The pectoral branch of this artery was present 43 times in
the 47 dissections. In the 4 cases in which it was absent its
area of distribution was supplied by a pectoral branch from
the axillary trunk in 3 cases (type VI), and in one case from
the subscapular (type VII), which shows the thoracic branch
present although small. This pectoral division of the acro-
mio-thoracic trunk is very variable in size, occasionally being-
large, in which case it supplies the pectoral muscles, the
second to fifth interspaces, and the serratus magnus and
latissimus dorsi. In those eases in which there is a long
thoracic artery present, it is smaller than in the first instance
and is limited to the pectoral muscles and the upper inter-
spaces. Occasionally it is very 'small, being merely a muscu-
lar branch to the pectoral muscles, and its area in this case
is more completely supplied by branches from the long thor-
acic, the subscapular or by pectoral branches from the main
trunk.

The clavicular branch is a small artery which was present
43 times in the 47 dissections. In the 4 cases in which it is
absent 3 cases show no artery to this area from any of the
axillary subdivisions; in one case it was supplied by a branch
from the main trunk. The acroniio-humeral branch is the
most constant subdivision of the acromio-thoracic, and in
those cases in which the pectoral branch is absent, it, with the
clavicular branch, forms the acromio-thoracic artery. In the
discussion of this subject under type VI, I have suggested that
this artery is merely the acromio-humeral artery and not the
acromio-thoracic, since it lacks the thoracic or pectoral por-
tion. Its distribution is also constant. In one case the
humeral or descending branch was small, the anterior cir-

cumflex artery in this case being large and sending off large
ascending branches to the deltoid and clavicular portion of
the pectoralis major. In 3 cases a branch is given off to the
subscapular muscle.

The Long Thoracic. — This artery was present only 11 times
as a separate branch from the a:silla.ry trunk (types II and VI)
and it was with this artery that the most trouble arose in
tabulating the dissections. The 11 cases here tabulated rep-
resent a large majority of the number found in all the charts
received. In discussing the question of the absence or pres-
ence of a major branch from part II. it is found that in 24
cases no major branch is found, while in 23 cases there is a
major trunk.

Instances in which there are no arteries from part II, tyjie
I, 20; type VI, 2; type VII, 2.

Instances in which there are arteries from part II, type II,
9; type III, 7; type IV, 4; type V, 3.

The cases in which the artery, arising from part II of the
axillary is the long thoracic, axe, however, less frequent,
that artery being present only in the 9 cases represented by
type II.

The long thoracic artery, as described by His, arises be-
neath the pectoralis minor, courses downward upon the ser-
ratus magnus to the fifth or sixth interspace, supplying that
muscle. The external mammary branches pierce the pec-
toralis major and supply the skin in the mammary region.
According to Testut, it arises beneath the pectoralis minor,
courses obliquely downward, inward and forward along the
lateral thoracic wall between the pectoralis major and the
serratus magnus as far as the fifth, sixth or seventh interspace,
where it terminates in anastomosis with the intercostal ar-
teries. As it descends it gives off numerous collateral
branches to the axillary glands, the subscapular muscles, the
serratus magnus, pectoralis major and minor, the intercostal
spaces, the mammary gland, and the antero-lateral region of
the thorax. According to Quain, the long thoracic artery
arises beneath the pectoralis minor, is directed downwards
and inwards along tlie lower border of that muscle and is
distributed to the pectoral muscle, the serratus magnus, and
the breast, forming anastomosis with the intercostal arteries.

From the above descriptions it is readily seen how variable
the distribution of the artery may he. My cases correspond
more nearly to the description given by Quain, although in
3 of the cases the artery corresponded with tlie description
given it by Testut.

The Subscapular Artery. — This artery varied consideralily
in its place of origin, coming from part I in 2 cases, from
part II in 8 cases, from })art III in 35 cases, and in 2 cases
from the trunk common to it, the long thoracic and acromio-
thoracic from part II. The common distribution of this
artery is that given it under type I. It may, however, vary
considerably, as is seen from the description given it in type
III. In four cases the artery was small, being practically
only the dorsal scapular artery. In these cases its remaining
areas were supplied by the long thoracic in 3 cases, and by a
large thoracic branch from tlic acromio-thoracic in one case.

142

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

(Sec table tj^pe I). The anterior and posterior circumflex
areas are also supplied hy this artery, the former in 2 cases
and tlie latter in 9 cases. In one case it also gave rise to tlie
sujierior profunda artery. The cases in which the suliscap-
ular included arteries usually arising from 'the axillary or
brachial trunks can be classified as follows:

Subscapular -j- posterior circumflex and superior profunda.

Subscapular + posterior circumflex,

Subscapular -(- anterior circumflex.

Subscapular -|- anterior and posterior circumflex.

The Anterior Circumflex. — The* origin of this artery w'as
relatively constant, conung from part III as a se])arate branch
ill 22 cases and from a trunk common to it and the posterior
circumflex in 21 cases. In the remaining 4 cases it took its
origin from the subscajnilar in 2 cases, from a trunk common
to it, the posterior circumflex and superior profunda in 1
case, and from the large trunk common to all the arteries in
1 case. Its distribution, as that given it under type I, was
constant except in that case in which it was given off from
the subscapular and supplied the area usually supplied by the
humeral branch of the acromio-thoracic artery, that branch
being small in this particular case. The cases in which the
anterior circumflex is united with arteries ordinarily arising
from the main artery may be grouped as follows:

.\nterior ami posterior circumflex,
Subscapular ami anterior circumflex,

" " " aud posterior circumflex,

.'1 cases.
1 case.
] "

4. Truuk.

.5. Truul<.

( Auterior circumflex, "j

.j Posterior circumflex. V

( Superior profunda J

C Acromio-tlioracic. "1

I Long thoracic. [

I Subscapular. J-

I Anterior circumflex. |

(^ Posterior " J

The Posterior Circumflex. — This artery was ]ierhaps the
most variable in origin of the axillary subdivisions being,
however, constant in its distribution (see type I).

The places of origin are as follows:

1. From axillary artery.

„ ™ , f Anterior circumflex.

2. Truuk. < n i ■

\ Posterior "

3. Subscapular.

13 cases.
21 "
!) "

I Posterior circumflex.
\ Superior profunda.
[" Acromio-tlioracic.
I Long thoracic.
i Subscapular.
j Anterior circ-uinliex.
[ Posterior "
Brachial artery.

4. Truuk.

.5. Trunk.

The 3 trunks recorded in the table have been described
elsewhere in this paper and are sufRciently clear from the
table itself. The remaining muscular, cutaneous and inter-
costal branches are infrequent and may or may not occur.
When present they are large or small as the case necessitates.
The branch labelled " axillary fascia " is that which is usually
described as the alar thoracic artery. It was present 8 times,
its area being supplied by the larger subdivisions of the main
arteries in their courses through the axilla.

The Posterior Scapular. — This artery arose from tlie axil-
lary artery in 5 cases. The artery in its course turns back-
ward, passes either between the trunks of the brachial jilexus
or passes over them, courses along the superior margin of the
scapula and then turns downward to pass parallel to the
vertebral margin of the scapula. In its course it gives
branches to the subscapularis, levator anguli scapuUv, tra-
pezius, rhomboid major and rhomboid minor, supraspinatus
and infraspinatus.

The suprascapular artery was found arising from the axil-
lary artery in one ease. In one case the superior profunda
was given oif in the axilla. In two cases not included in these
records the axillary artery divided into the i-adial and ulnar
in the axilla, and in these cases the anterior and posterior cir-
cumflex arteries and the superior profunda were given off by
the radial.

The conclusions to be drawn from this study are:

(1) That while the origin of the subdivisions of the axillary
artery varies, the distribution is practically constant.

(2) That type I, as here described, is the ordinary form in
which the axillary artery is found.

(3) That the long thoracic artery and alar thoracic arteries
are most frequently absent and that their areas of distrilm-
tion are supplied by the adjacent branches from the main
artery.

TABLE SHOWINCx THE ORIGIN AND DISTRIBUTION OF THE BRANCHES OF THE AXILLARY ARTERY

IN FORTY-SEVEN CASES.

Origin.

STKIBUTION

ft)

p.
n

^ o

o
c

4-1

BRANCH.

n
O

a -a
.2§

•a
i

a
o

be
03

'i
■§

<»

3
'o

a
o

W
s- OS

•3

—
3

C3
PL,

ft>

S3
u
o

2 a

° 2
u S

>
J3

3
03

sterio
scapu]
perior

a
s.

■d

C-l

■*

3
GO

3
OQ

0)
00

^ ^

Superior thoracic

Acromio-thoracic

7
1
2

24
4
6

6
11
33

1
1

38
8
8

4.S

3
5
43

3
41

Long thoracic

Subscapular

April-Mat-Junjs, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

143

Origin.

Distribution.

BRANrll.

■3

(ft

*C8
to

0
0
It

a
a

0
0

1— (

3J
U
03

0
'5*

u
a
p4

0
a

■3
0
0

•a
•11

a a

in 0

is
ss

fl4

o3-
GO

03
03

a
0

m
;^

I-
lU

'to

-5

■c

3
0

.2
"0

o3
>%

2
3

0
0

C
0

It'

■5

a
0

■Jo

.2 9

-3

2
0

t-.

a
1;

•3

CU
03

Auterior circumflex

Posterior circumtlex

Trunk common to anterior iiuJ pos-
terior circumliex

Trunk common to circumflex arteries
luul superior profiuulii

32
13

31
2

•

1
0

3
3

9
.5

•3

3
31

•^

3
1

•■

2
2

To subseai)ularis

15
1
3
3
5
1
1

1
1
1

.5 1

6 ..

1 ' ..

'2 "5

3 1 4

1 lil

1 1 19
1 ' 1

.. i ..

To pectoralis major

'I'o pectoi'alis minor

I'ectoral Ijraneli

To subclavius ami clavicle

To axillary fascia

Articular

1 st and 'Jnil interspaces

riiiil iuterspace

To coraco-brachialis .... . .

....
i
1

1 . .
- ■ 1 . .

301 ..

* * 1 ■ ■

Posterior scapular

Superior profunda

TYPE I, 20 CASES.

BRANCH.

Orioin.

Distribution.

■" ?

-5 1

i-i4

ta '

REM ARK. S.

1. Superior thoracic

2. Acromio-tboracic

3. Subscapular

4. Anterior circumflex .

5. Posterior circumflex ,

9.
10.
11.
12.
13.
14.
l.i.

Trunk common to anterior and
posterior circumflex arteries.

To M. subscapularius

To pectoralis major

To pectoralis minor

Axillary irlands and fascia

Articular

2nd and 3rd interspaces

Coraco-bracliialis

Biceps

Posterioi- scapular

.51
lHil9

( In the absent case the region
-1 was supplied by the acromio-

upplied by
thoracic artery.

8. times from a branch com-
mon to circumflex arteries
(see line 6).

8 times from branch com-
mon to circumflex arteries,
4 times from subscapular,
1 case from brachial artery
(see lines 3 aud (i).

144

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

TYPE II, 9 CASES.

Origin,

Distribution.

BRANCH.

V
03

P.
CO

1— (
•a

CA
1>

03
n

1-^

<»

■3

P-i

0
*-"

° .2

la
p-i

3
CO

9
ft

. o3

QQ 0

■« 03

OS _tO

1.1

" I'So

^1^

co'

'co
t-

•a

v
m

0
Ph

3
a

to
03

"bt,
!>.
03

.2
a

1
0

a
0

2 3

2-(

03
t3

3
3

u
P.

.2
'n

3
00

§•
0

REMARKS.

7
9

7
3

4
3
2

3
3
9

9
3

5
6

7
1

6
6

5
9

9
6

1
0

4
4

■■

Absent twice, supplied by
\ acromio and long thoracic

Acromio-thoraeic

(see lines 3 and 3).

Pectoral branch absent twice,
, area supplied by long thoracic
' (line 3) and pectoral branch
(line 11).

( Large in 3 cases, supplying
J the subscapular area in part

( (see line 4).
Small in 0 cases, being confined
to dorsal and scapular region

4
3

principally (see text).

For remaining place of origin
see lines 4 and 7.

( For remaining places of origin
j see lines 4, 7 and 8.

f For other origins of circumflex
\ arteries, see lines 4, 5, 6 and 8.

7. Trunk, common to anterior and

posterior circumtiex arteries .

8 Trunk

9. Branch to M. siibscapularis

1
2

1 1 Pectoral lirauch

12 Articular

•;

TYPE III, 7 CASES.

]

1
1

3
1

4
4

3
.5

7
2

1
3

4
3

( Absent once, supplied by
■1 acromio-thoraeic and sub-

3. Acromio-thoraeic

( scapular.

4 Anterior circumtiex

For 3 remaining cases see line 6.

5. Posterior circumflex

6. Trunk, common to anterior and

Ijosterior circumflex

7. M. subscapiilaris

8 M coraco-bracbialis

]
1

1
1

J From subscapular in 3 cases.
} From trunk (line 6) in 3 cases.

See lines 4 and .5.

10 Articular . .

11. 1st and 3ud interspaces

12. Br to deltoid

13 M pectoralis minor ...

April-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

145

TYPE

IV,

4 CASES.

Origin

Distribution.

■
BRANCH.

rt
^

as
P.

a
m

+->
a

o
a

rXi

V3
1/1

3
D.
si

33
cfi

O
-O

o
'Sii

o
■a

m
'■H

o
Ph

t-.
*:j

w
T3

CI
t^

o
o

3
o

«1

03
CJ

-«J
m

O
Ph

03
T3
3
3

CH
O
^

_o
a

REMARKS.

1. Superior thoracic

8. Acromio-tlioracic

1
1

4
3

1
4

1
o

1
1

•
1

j Absent once, supplied by acro-
( mio-thoracic (see line 2).

4 Anterior circumflex

j For 3 remaining cases, see lines

( 3 and 6.

6. Circumflex trunk

See lines 3 4 and 5

8. M. coraeo-brachialis

9. M. biceps

j No branch from axillary, supplied
( by brachial in 1 case.
Same.

Represented by a definite branch
twice (see line 3 for 1 case)

13. Posterior scapular

remainder supplied by various
arteries.
See text

13. Superior profunda

See text

TYPE

, 3 CASES.

1. Superior thoracic

1
2

I
2

1
2

1
3

1
1
2

1
2

1
1
2

1
3

1
2

1
3

3. .\cromio. thoracic

3. Subscapular

See lines 2 and 3.

5. Anterior circumflex

6. Posterior circumflex

7. Trunk, common to anterior

posterior circumflex

and

TYPE

2 CASKS.

1. Superior thoracic "

2
3
3

1
1

"i
1
1

2
'3

1
1
2

2
1

1
1

3
2

I ■

1
1

■■

• ■

i Pectoral branchabsent in onecase
-j and small iu the other. Sup-
( plied by pectoral branch (line 8)

I Teres major supplied by dorsalis
^ scapular, getting no branches
( from subscapular direct.

See line 7 for remaining origin.

See line 7.

See lines r^ and 6.
See line 2.

3. Long: thoracic

4. Subscapular

.5. Anterior circumflex

tJ. Posterior circumflex

7. Trunk, common to anterior aud
posterior circumflex

8. Pectoral branch

9. Articular

11. Biceps

See line 2 for remaining case.

TYPE

VII,

2 CASES.

1
2
3

I
1

1
1

2
1

1
1

1
3

1
1

See lines 3 and 8.
("Pectoral branch absent iu 1 case
(see line 8), supplied by pec-

2. Acromio-thoracic

toral branch and by sub-

[ scapular (see line 3).

4. Circumflex trunk

For remaining case see line 5.
See line 4.

.5. Trunk

7. Pectoralis minor

8. Pectoral branch

j See line 3. Supplies pectoral

9. Axillary glands aud fascia

I area of acromio-thoracic
Was present as a rather large
artery both in this case and
in that from the subscapular
(see line 3).

146

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

ON THE ORIGIN OF THE LYMPHATICS IN THE LIVER.

By Franklin P. Mall,
Professor of Anatomy, Johns Hopkins University.

The ori<Tin of the lymphatics of the liver was first deiinitely
determined hy MacGillavry," who studied this subject under
the direction of Ludwig. Long before the work of Mac-
rjillavry it had been observed that ligature of the bile duct
was followed by passage of bile over into the lymphatics, and
the artificial filling of the lymphatics naturally followed by
injecting a colored fluid into the bile duct. Sections of liver,
in which the lymiihatics had been filled with Prussian blue,
or with as]ihaH, showed that the fluid injected into the bile
ducts leaves them at the periphery of the lobule to enter
spaces surrounding the blood capillaries, the so-called peri-
vascular lymph spaces. These spaces communicate at the
]ieriphery of the lol)ule directly with the interlobular lymph
channels. Frequeiitly there is an extrava.«ation of the injec-
tion mass into the blood capillaries of the lobule.

These observations were subsequently confirmed by numer-
ous competent investigator.?, using the method employed by
MacGillavry as well as that of direct injection of Prussian bhie
into the walls of the portal and hepatic veins. In successful
injections made in this way it is found that the Prussian blue
injected enters the lobule to encircle its blood capillaries."
Such injections, however, are always accompanied with num-
erous extravasations of the injected material into the tissues
])etween the lobules, and often there is a secondary injection
into the blood cajiillaries of the lobule. This fact has raised
an objection to the dii-ect injection of the lymphatics from
the bile capillaries. It appears more probable, the opponents
say, that the extravasation of bile, or the injected material
into the interlobular spaces, enters the lymphatic radicals of
the capsule of Glisson, and from them the larger lymph clian-
nels and the perivascular spaces of the capillaries are tilled.
Furthermore the injected mass may pass from the pericapil-
lary spaces directly into the capillaries, thus accounting for
their frequent injection.

According to Fleischl,' all tlie bile is taken up by the
lymphatics after ligature of the bile duct, and in case the
thoracic duct is also ligated no bile or only a trace of bile
ever reaches the blood. The observation of Fleischl has been
confirmed by Kunkel,' Kufferath ° and Harley." It is ex-
tremely difficult to understand why the bile does not enter the
blood capillaries in case it passes from the bile capillaries
over into the perivascular spaces before it reaches the inter-
lobidar spaces after ligature of the bile duct. A further
objection to the idea that the perivascular spaces first take up
the bile, after ligature of the duct, is the fact that fluids

1 MacGillavry, Wiener Sitzungsber., 1SG4.
- Budge, Ludwig's Arbeiten, 187.5.
3 Fleischl, Ludwig's Arbeiten, 1874.
■> Kuukel, Ludwig's Arbeiten, 187.5.
!• Kutlenitb, Arch, fur Pbysiol., 1880.
"llarlcy, Arcliiv fiir Physiol., 1SH3.

injected into the bile duct pass with ease over into the
lymphatics but only with difficulty into the bile capillaries.
In all cases it appears as if the main origin of the lymphatics
is at the periphery of the lobule and that the radicals commu-
nicate freely with the perivascular lymph spaces. Further-
more, it appears that the course the bile takes after ligature
of the bile duet, or of a fluid injected into the bile duct in
passing to the lymphatics, is between the lobules or at least
at their extreme periphery. This idea is greatly strengthened
since we know that the walls of the capillaries of the lobule
are extremely porous, being composed of a dense layer of
reticulum fibrils ' upon which lie the endothelial or Kupfl'er's
cells. This layer of reticulum fibrils encircling each capillary
has been described from time to time by many investigators,
and has been isolated by Oppel ° and by myself.' Oppel ob-
tained clear pictures of the connective tissue of the liver lobule
by means of silver ])recipitatioii, while I employed Kiihne's
method of pancreatic digestion to remove the cells, followed
by some intense stain like acid fuchsin. The nature of theso
fibrils is still under discussion but that matters little for the
present communication. It is sufficient to know that flic
fibrils of reticulum form a basket-like membrane surrounding
each capillary of the whole lobule, the interior of which is
only partly lined by Kupffer's syncytial endothelial cells.
The capillary walls then are very pervious, blood plasma pass-
ing easily from them out into the perivascular spaces to bathe
the liver cells.

It is well known that a large quantity of lymph is con-
stantly passing from the liver, much more than from any
other organ. That this lymph comes directly from the blood
is indicated by its high per cent of proteid matter, nearly that
of the blood, and from two to three times that of the lymph
from other parts of the body.

The course the lymph takes from the blood to the lymph
radicals, i. e. its natural course, can easily be marked by
injecting colored gelatin into any of the blood-vessels. 1
have usually found it most convenient to inject the gelatin
into the portal vein, but it is just as easy to fill the lymphatics
by injecting either the hepatic artery or hejiatic vein. In all
cases the colored fluid reaches the main lymph channels in
the same way. The colored gelatin flows with great ease
from the capillaries at the periphery of the lobule as well as
from those around the sublobular vein into the lymphatics.
After the lymphatics have all been filled it is well to inject
a small quantity of fluid of different color into the blood-
vessels. A much better method of making double injections
is to mix red granules with a blue gelatin or blue granules

1 Kupffer, Arch. f. Mik. Anat., ^4.

•* Oppel, Arch. Anz., 1890.

'Mall, Abhaudl. d. K. S. Ges. d. Wiss., .xvii, 1891,

April-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

147

with a red gelatin, the fenestrated lining membrane of the
capillary acting is a sieve which allows the fluid to pass but
holds back the granules, as is the case with the blood wheu
normal circulation is taking place.

If the portal vein is injected with Prussian-blue gelatin
under a low pressure, it is found that in a few minutes the
lymphatics are all filled with the blue mass. Jjivers injected
in this way are best hardened in formalin and then cut by
tJU' freezing method, for alcohol causes the gelatin to shrink.
Such sections show that the blue fluid has entered the lym-
|)haties at the periphery of the lobule. More instructive arc
the specimens when the injection is stopped just as the first
lymjihatics are filled with the colored gelatin. By following
the larger lymphatics back into the liver substance it is found
that the interlobular connective tissue is entirely filled with
blue where the lymjihatics are injected, but only partly col-
ored blue when they are not. In other words, the blue extra-

■-■ - • /©./ L

Fig. 1. — Section throuj^h tlie periphery of the liver lobule of a cat.
The hepatic artery was iujecteii with cinnabar gelatin, ami the portal
vein with Prussian-blue gelatin, stained with Van Gieson's stain, x .500
L, lobule of liver ; <■, oapillarios ; a, artery; ?, lymph vessel; pi'l, times,
perivascular lymph space ; pW, perilobular lymph space; w, bundles of
fibrils of white tlbrous tissue.

vasates from the jieriphery of the lobule, invades the connec-
tive tissue until it reaches the beginning of the lymphatics,
when of course it is carried rapidly from the liver. The near-
est course from the lobules to the lymphatics is between the
lobule where the amount of connective tissue is small, so
when colored fluid is beginning to enter lymph channels the
tips of the capsule of Glisson are entirely colored, while
larger portal spaces are encircled by a zone of the color.
Furtliermore it is found that in certain instances when the
injection was not continued long enougii tlie libu^ did not
enter the lymphatics. In such specimens it is found that all
the interlobular spaces are surrounded by a zone of colored
gelatin which does not enter the main lymjih channels.

A successful injection of the lymphatics is illustrated in
the accompanying figure. The section was stained with Van
Gieson's stain which gives a very satisfactory result. The
granular blue enters the capillaries of the lobule, c, with ease.

and from them the liquid blue is filtered through the capillary
walls to enter the perivascular lymph space. This space
communicates at the periphery of the lobule directly with a
large lymph space between the liver cells and the capsule ot
Glisson, which I shall term the perilobular lymph space.
These spaces in turn communicate with the lymph radicals.

Injection of the blood-vessels of tlie liver with aqueous
Prussian blue fills the capillaries only, and in all cases it is
shown that there are no capillaries between the periphery
of the lobule and the interlobular connective tissue. The
liver cells come directly against the capside of Glisson. An
injection of brief duration with blue gelatin soon fills the peri-
lobular lym])h spaces, so that it appears as if all groups of
liver cells at the periphery of the lobule were separated from
the interlobular connective tissue with capillaries. In ease
cinnabar granules are mixed with the blue a few of these
granules are found in the perivascular and perilobular lymph
spaces. The openings in the walls of the capillaries are large
enoiigh to allow a few of the smaller granules to pass through.
As the injection is continued the blue invades the connective
tissue spaces from the lymphatic radicals more and more
until a lymph channel is reached, when of course it flows
rapidly from the liver. -Were there a direct channel from
the perilobular lymph spaces the blue should flow through
it at once without further filtration through the interlobular
connective tissue spaces. The course the cinnabar granules
take also speaks against a direct channel between the peri-
lobular lymph spaces and the interlobular lymph channels.
A few of the granules enter the ]ierilolnilar lymph sjiaces, but
none of them reach the main lymph channels. All of my
specimens without exception force me to the conclusion that
there are no direct channels connecting the perivascular and
perilobular lymph spaces with the lymphatics proper other
than the ordinary spaces between the connective-tissue fibrils
of the capsule of Glisson. These spaces, however, are rela-
tively large, permitting of a rapid diffusion through them.

Interstitial injections into the walls of the interlobular
veins natui-ally liU the surrounding lymphatic vessels, and
when no valves are in the way the injected fluid passes to the
origin of the vessels, or lacunte, which are only in part lined
with endothelial cells. From here the fluid passes through
the main connective-tissue spaces to the periphery of the
lobule into the perilobular and perivascular lymph spaces, and
frequently from thtm into the blood capillaries. When the
injection is made through the bile ducts I have always found
that there is an extravasation of the fluid from these at the
periphery of tlie lobule which immediately enters the lymph
radicals, although the bile capillaries are often injected well
into the lobule. The extravasation docs not take place from
the bile capillaries, only from the duct as it communicates
_with the capillaries; also it does not take place from the larger
bile ducts. Such extravasations naturally are picked up by
the lymphatics and are at once carried from the liver. If
after ligature of the bile duct the bile enters the perivascular
lymph space within the lobule it may still be carried to the

148

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

lymphatics, as the direction of the current of lymph is con-
stantly from the blood capillaries to the lymphatics.

It is well known that the liver cells arise from the eni-
biyonic bile dncts. and that in the further growth of the liver
the bile ducts must elongate in order to adjust themselves
with the growing liver. Hendrickson '° has shown by staining
the bile capillaries and ducts of tlie embryo's liver by Golgi"s
method that the tip of the primitive l)ile duct is added to by
a coalescence of the bile capillaries at the periphery of the
embryonic liver lobule. My own observation on the liver
lobule after it is well formed is that whenever karyokinetic
cell figures are present they are at the periphery of the liver
lobule, i. e. at the junction of the bile capillary with the bile
duct. It also appears that the vascular walls of the embryo
are much more pervious than those of the adult. Judging by
the ease extravasation takes place when the blood-vessels of
embryos are injected. This observation taken with that ol
the growth of the bile ducts may be an explanation why the
e.xtravasation of a fluid injected into the bile duct takes place
at the periphery of the lol)ule. A further hint in this direc-
tion is the observation that it is easy to inject the lymphatics
from the blood-vessels of an inflamed area. I have often seen
the lymphatics of an inflamed intestine filled with blood, and
upon injecting the blood-vessels found that the fluid readily
entered the lymphatics."

'"Hendrickson, Johns Hopkins Hospital Bulletin, 1898.
" See also Sigmund Mayer, Anat. Anz., 1.S99.

That the capillaries of the liver communicate more freely
with the lymphatics than do the bile ducts is jiroved by in-
jecting the bile duct and the portal vein with fluids of dif-
ferent color under the same pressure at the same time. In
all the experiments I made the fluid injected into the vein
appeared in the lymphatics first. In many instances beautiful
injections of the lymphatics were obtained from the vein
while the fluid injected into the bile duct did not extravasate
at all, showing at least that the veins communicate with the
lymphatics much more freely than do the bile duets.

The conclusions to be drawn from the above observations
are (1) that the lymphatics of the liver arise from the peri-
lobular lymph spaces and that these communicate directly
with the perivasculai" lymph spaces; and (2) that the lymph
reaches these spaces by a process of filtration through open-
ings which are normally present in the ca|)illary walls of the
liver. Fiirthermore, the fluid injected into the lymphatics
from the bile duct leaves the duct as it enters tlie lobule and
is at once taken up by the lymph radicals and perilobular
lymph spaces, and from tliem extends, as a secondary injec-
tion, to the perivascular lymph spaces, and often into the
blood capillaries of the lobule. The larger lymphatics accom-
panying the portal vein arise between the lobules near their
bases, while those accompanying the hepatic vein do not arise
within the lobule but around the larger sublobular veins.

BORN'S METHOD OF RECONSTRUCTION BY MEANS OF WAX PLATES AS USED IN THE
ANATOMICAL LABORATORY OF THE JOHNS HOPKINS UNIVERSITY.

By Chahles Eussell Bakdeen,
Associate in Anatomy, Johns Hopkins University.

The wax-plate method of reconstruction (Plattenmodellen
methode) described by Born in 1876 ' has proved of great
value in the study of the morphology of embryos. The
method has received its most extensive application in the
hands of Born, of His and of various pupils of these investi-
gators. In general, however, it may be said, that the value
of this method as an aid to the microscopic study of form has
not been sufficiently appreciated.

In part this lack of a more general application of the
method has been due to certain technical difficulties which
tend to make it cumbersome and time-consuming. Yet by
no other method can so accurate an idea be obtained of the
form of those structures which from their minuteness or
complexity of relation cannot well be dissected out.

Considerable application of the method has recently been
made by different persons in this institution and each worker
has contributed something towards making the method more
effective.

I Morph. Jahrb. II; Arch. f. mikr. Anat., xxii, p. 584.

As originally described by Born several steps are essential
for the successful application of his method. These may be
tabulated as follows:

A. Preliminary steps.

1. Obtaining a good picture of the embryo or object to be
reconstructed.

2. Hardening, staining and sectioning the object.

3. Drawing magnified enlargements of the sections or such
parts of them as it is desired to reconstruct.

4. Preparation of the wax plates.

5. Transference of the image to the surface of the wax
and cutting out the wax plates.

B. Constructing the model.

1. Piling the wax plates.

2. Removing parts not essential to the reconstruction de-
sired and rounding oft' of the parts reconstructed.

3. Strengthening and finishing the model.

I shall consider these steps in the order named.

A. Preliminary steps.

1. Before proceeding to section the object to be recon-

April-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Ui)

structed it is important to obtain good pictures of its external
form. With such a picture at hand it is much easier to pile
up the wax plates which represent the sections through the
object. This is especially true when the object is symmet-
rical, as in the reconstruction of embryos, profile views of
which are invaluable in this work. If the picture be enlarged
to the magnification of the model desired a valuable control
is furnished. A series of parallel lines may then be drawn
through the picture to represent the planes through which
the knife has passed in sectioning the embryo, so that the
position of every plate is indicated.

For general purposes photography is undoubtedly the most
convenient method of recording the gross external features
of the object. If the object be very small as, for instance, an
early human embryo, the camera may be so placed that the
image in the negative is enlarged from two to four diameters.
It is found that the most convenient way of photographing
embryos is to place the camera wdth the axis in a vertical
direction and the lens pointing downwards. A stand for
holding the camera in this position and raising or lowering
it is easily constructed. Ordinary lead shot seems to be
especially good for holding many small objects in the posi-
tion in which it is desired to photograph them.

For detail in the distant as well as the proximal part oi
the object it is a great aid to make use of a stand capable of
being raised without moving the object laterally. In this
way, if the diaphragm be closed down so as to make the
exposure a long one, the object may from time to time be
brought slightly nearer to the lens of the camera, so that
parts more distant are brought into sharp focus.

From the photographic plates thus obtained lantern slides
are made or the negative itself is used to project the imag.
at the required magnification upon a screen. Free-hand
drawings are then traced on a paper upon which the image
falls, or, if desired, bromide enlargements can be made. In
this way accurate records can quickly be made of the external
appearance of the object to be studied, yet no special talent
for drawing is required. In the study of embryos the jirofile
view is the most essential one, though others also prove of
great value.

2. The only real essentials in the technique of obtaining
serial sections of the object to be studied are that the series
should be complete, the sections perfect and of uniform thick-
ness. As pointed out by Born, the most convenient sec-
tions for this work are those from 20-40 microns in thick-
ness. For sections of this thickness we have found alum
cochineal to give uniformly the most satisfactory stain. It
is important to know which side of the sections was upper-
most during the cutting, so that in the subsequent reconstruc-
tion a true and not a mirror image of the object will be
formed. For this reason it is well to make it a uniform
practice to begin at the head when cutting transverse sections
through an embryo, at the right side when cutting longitu-
dinal vertical sections, and at the dorsal side wlien cutting
liorizontal sections and to label the sections in the order in
which they have been cut.

3. For making drawings of the sections we have found
that in general a projection apparatus is more convenient
than a camera lucida unless the sections are small. Our pro-
jection ajijiaratus is set up in a large dark room.

The illumination is received from an arc electric light or
from a heliostat. An ordinary microscopic stand with the
tube in a horizontal direction is used when the sections are
small and a high magnification is desired. Eye piece and
draw tube are usually removed and the objective is used as
the magnifying lens. In case of larger sections a projection
lens similar to that used for lantern slides is utilized.

The image is projected upon a screen which runs on a
track. The screen can be moved toward or away from the
microscope by means of windlass situated near by. In this
way any desired magnification can be quickly obtained by
using an appropriate lens and bringing the screen into the
proper position.

The screen which I devised for our dark room has attached
a leaf which can be lowered so as to form a drawing table and
a mirror that can be placed at an angle of 45° over the
table. In this way the image is projected on a horizontal
surface so that tracing it is easier than when it is upon a verti-
cal surface. In using an ordinary mirror a double image is
projected but that from the surface of the mercury is so much
brighter than that from the surface of the glass that no diffi-
culty is experienced in drawing accurate outlines.

Fig. 1 illustrates the apparatus here in use.

Fig. 1. — At the right the projection screen is shown in position on
the tracli. The mirror is lowered to an angle of 45° and the drawing
table is extended horizontally below this. At the left are shown the
windlass used for moving the projection screen and the shelf used for
holding the projection lantern.

In drawing pictures of the sections a careful outHuo of
those main features which it is desired to bring out in tlu'
reconstruction is the great essential. In addition it is often
of value to distinguish by using pencils of various colors the
different organs in structures as they appear in the section.

If desired, direct bromide enlargements can be made of the
sections on the slides. This is the method preferred liy His.
The simpler method described above we have found, liow-
ever, to be more convenient for general purposes.

The outline drawings may often be elaborated to any de-
sired extent when the sections are subjected to carefvd micro-
scopic study. It is a great help for the subsequent recon-
struction to label, so far as possible, the various structures in
the outlines of the sections before proceeding to the wax
plates.

150

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-123.

4. Much trouble in the preparation of the wax plates is to
be saved by using plates of a uniform thickness and by mak-
ing the magnification of the object under reconstruction cor-
respond. The most convenient thickness for general use is
2 mm. Occasionally, for coarser work, 4 mm. plates have
proved of value. It is very easy, with the apparatus above
described, to make the ratio of the dianftter of magnification
of the drawings to the diameter of the sections equal to that
of two millimetres to the thickness of the section. If plates
2 mm. thick be used and every section be drawn, sections
20 mm. thick = 1/50 mm. must be magnified one hundred
times. Or if desired, as is more often the case, every other
section may be drawn at a magnification of fifty diameters.

For making the wax plates we have a large zinc pan with
vertical sides. Its surface area is such that one kilogram of
the wax mixture which we use will make a plate 1 mm. thick.
The method of casting the plates is essentially that described
by Born. Boiling water is run into the pan to the deptli
of several inches. On the surface of this the hot melted
wax mixture is poured and quickly forms an even, smooth,
layer. Bubbles, which occasionally appear in the wax, may
be quickly exploded by turning the flame of a Bunsen burner
on the surface of the wax where they appear. As the wax
plate cools it is necessary to free it from the sides of the pan
by running a knife along the edge. Before the plates are
perfectly cool they may readily be cut into smaller plates of
any desired size.

The wax mixture in use here is composed of 950 parts of
bees-wax and 50 parts of white rosin. Often, especially in
summer, paraffin is added to give additional toughness. Black
plates are made by adding lamp black to the melted wax,
until after thorough stirring the mixture has become uni-
forndy black. The amount by weight of wax necessary for
a plate of a given size is obtained more easily by experimental
trial than by calculation. A certain amount of wax becomes
attached to the sides of the pan by surface tension, so that
slightly more wax must be used than the amount one is likely
to determine by calculation from the specific gravity of the
wax and the size of the ])an. On the other hand if a pan
of a given size be used the amount of a given wax mixture
necessary for making a plate of given thickness may be deter-
mined by a few trial castings.

The outlines are transferred to wax by means of red or
blue tracing paper. The wax plates are then placed upon
glass and are cut with a small, narrow knife and in a warm
room.

B. Constructing the model.

1. The janitor can be trusted to trace the outline drawings
on wax, to cut througli the wax with a sharp knife where the
outlines are traced and to make the preliminary piling.
Usually two preliminary piles are made, one of that part of
the wax plates which represent the sections and one of the
wax plates themselves after removal of the parts repre-
senting the sections. From the former a positive, from the
latter a hollow negative image of the original object is ob-

tained. In this piling an enlarged picture of the object is of
very great help. As originally suggested by Born, in case of
symmetrical objects a surface outline may be drawn on card
board and cut out, thus giving a fixed ridge against which to
pile the plates. If but one side of any embryo is to be recon-
structed from transverse sections it is of great help to cut
each plate off sharply at the midline and to pile the plates
against a profile outline of the embryo situated on a Ijoard
which has been placed ]ierpendicular to the plane in which
the plates are piled. In case the reconstruction of some
internal organ is wanted it is usually of advantage to re-
construct at the same time the external form of the ob-
ject, so that when the jjlates are piled the iiuage they form
may be compared with the picture of the original object.
After getting the plates composing the positive image of the
object into proper position, it is easy to trace two or three
of its surface curves on paper or to represent them in wire
and then to get the negative formed, as described above, into
true shape. Plaster casts can then be made in this negative
mould. The plaster casts, representing the external features
of the original object, are very valuable to have at hand,
while engaged in reconstructing the internal features from
the wax plates.°

The method of making every fifth ]ilate a black one ha-^
proved to be extremely valuable in arranging the wax jilates.
In this way it is easy at any time during the reconstruction
of the model to count up and place any given section.

The method of reconstruction which I have found most
convenient is as follows: After the "plates are placed in
proper jiosition so that the external features of the object
are accurately portrayed, I begin by taking oil' five plates from
one side. The draAvings of the sections I likewise have
pinned together in groups of five in the same order in which
the plates are piled. By going over the five finished draw-
ings it is easy to obtain a good conception of the form of the
structures represented in the block of five plates under ctm-
sideration. I have at hand a paper of fine pins and these 1
l)ress down through the various structures seen in section
on the surface plate, and in such a direction that they will
pass into the same structure in the sections below. When
the parts of the plates which represent the structures to l)u
reconstructed are thus firmly united by pins I remove the
intervening portions of the wax plate with a pair of force] s.
Thus, in a very short time, one is enabled to l)ring to light
the form of the structures lying within the block of five
sections. The pins hold the various bits of wax firmly in
place and serve to strengthen the model in every way. When
I feel satisfied with the appearance of the structures in the
first block of five sections I proceed to the next and treat it
in the same way. Those structures which are cut in both
liloeks of sections may at the same time be ])inned together.
After two or three blocks of sections have thus been piled
up it is often well before adding another lilock of five sec-

■J Many methods liave been devised of pilini; plates acciirdhiir to
special marks. The method devised by Wilson, Zeitschrift fiir wissen-
shaftliche Miliroscopie, xvii, IDOO, page 17T, seems a good one.

April-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

151

tions to fuse them together with a hot knife and thoroughly
to strengthen the reconstruction so far as it is completed.
For strengthening piles of narrow strips of wax, representing
sections through membranes and the like, a wire netting is of
the greatest value. Perhaps the best form of wire netting
for general purposes is a copper netting with 10 strands to
the centimetre. The copper netting has no tendency to
cause subsequent warping, as is the case with iron netting.
The netting is heated in the flame of a Bunsen burner and
is then applied to the surface which it is desired to strengthen.
In case of narrow columns, such, for instance, as are formed
in the reconstruction of blood-vessels and nerves, copper wire
is of the greatest value. This can be heated and sunk in at
one side and then fused over.

After the model is once well started the subsequent build-
ing up can proceed with great rapidity. Plates in blocks of
five are added as described above until the model is finished.
Of course a greater or less number of plates than five may be
used to a block. In most of my work, however, I have found
blocks of five, with a black plate on the surface of each block,
to give the most satisfactory results.

In order to keep the various structures distinct during the
reconstruction it is often of value to paint them with dilferent
colors, while the work proceeds. The various structures of a
model built up as described may be removed as completed,
or during the course of reconstruction, and then readily re-
placed. Pins are of great value in holding structures iri

place and for indicating where a structure removed must be
replaced in order to regain its proper position.

If it is desired at any time to cut the model in a given
direction the pins which hold the pieces of wax together
may be readily cut with scissors.

3. I have mentioned methods by which ihe model is greatly
strengthened during the course of reconstruction, the use of
])ins, of wire netting and of wire. All three means may be
employed thoroughly to strengthen the mod«l after the first
rough reconstruction. The wire screening is then especially
valuable. Of course it is possible to add free hand and with
a good deal of accuracy structures which from their delicacy
are diflicidt to model. This is true of blood-vessels, nerves
and of fine membranes. The blood-vessels and nerves may
be readily constructed by covering copper wire with wa.x,
the membranes by covering a netting of narrow meshes with
a thin coating of wax.

In rounding and smoothing up various structures in a
model so as to give it a finished appearance, semi-melted wax
a])])lied with the fingers or with a spatula is of the greatest
help.

Tlie model is greatly protected in many ways by a thick
coating of paint. Hot weather seems to have a far less detri-
mental effect on such models than on models unpainted.

We have found jihotograjdiy of great help not only in re-
coi'ding the condition of the finished model but also, at times,
during the course of a reconstruction.

MODEL OF THE NUCLEUS DENTATUS OF THE CEREBELLUM AND LPS ACCESSORY NUCLEL

By Harry A. Fowler.

(From tJu Aniilomictrl Lahoyaionj of the Johns Hopkins University.)

At the suggestion of Dr. Barker I have undertaken the
study of the central gray matter of the cerebellum and its
relations to the white fibre bundles to which it is intinuitely
related. It has seemed advisable to make a partial report
including a reconstruction in wax of the nucleus dentatus
and its accessory nuclei.

In a study of the internal structure of the cerebellum it
is necessary to consider the work of Stilling on this region.
To him belongs the credit of being the firet to study the
internal anatomy of the cerebellum by means of serial sections
made in various planes and stained with dyes to bring into
greater contrast the white matter and the gray masses.
With the crude methods at his disposal for preparing serial
sections and staining them, the drawings of Stilling show
with remarkable accuracy the relations of these central nuclei
to the white substance in which they lie buried and to which
they are closely related.

The Material. — The model was made from a series of trans-
verse sections through the medulla and cerebellum of a new-
born babe prepared by Dr. John Hewetson in the Anatomical
Laboratory of the University of Leipzig. The material was
hardened in iliiller's fluid, cut ^0/'. thick, and stained bv the

Weigert-Pal method. Every other section was used and
hence each section represents a thickness of 110 microns.
A series of sagittal sections through the medulla and cere-
bellum of a new-born babe was also prepared and treated in
a similar way for use as a control in measurements and to
furnish an outline of the floor of the fourth ventricle. This
outline was used in building up the model.

The Method. — Bern's method for nuiking wax jilates as car-
ried out in this laboratory has been fully described by Dr.
Florence R. Sabin.' A magnification of twenty diameters
was decided upon, because (1) it gives a plate of convenient
size to work with so that the numerous foldings of the surface
of the dentate nucleus can be distinctly outlined, and (2) the
thickness of the jjlates — 2.8 mm. — makes them easy to cut
and convenient to liandle — two points of considerable practi-
cal value. Outline drawings were nuide first with a projection
apparatus at a magnification of twenty diameters. These
drawings were then controlled with a higher magnification
before transferring them to wax plates.

In building the model a real difficulty presented itself — the

' Sabin, Contributious to the Science of Medicine, and .Jolins Hopkins
Hosi)ital Reports, ix.

152

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-133.

difficulty of controlling the curves. Inasmuch as the central
nuclei of the cerebellum lie deeply buried in the wliite mat-
ter of the hemispheres and worm one does not have tlie
assistance afforded by external form in building up the model.
In studying the sections it was noted that the dentate nucleus
and accessory nuclei are bisymmetrieal, and a prolongation
of the raphe of the medulla dorsalwards Ijisccted the cere-
Ijellum, passing through the middle point in the roof of the
fourth ventricle. Corresponding points in the nuclei of the
two hemisjiheres were equidistant from the median line so
drawn and from the middle point in the floor of the fourth
ventricle. In building the model these two guides were used:
(1) the median line which controlled the lateral curve, and

to the lowermost (distal) section, in which the dentate nucleus
appeared, was placed at a proper distance from the median
line, i. e. the edge of the board and the upriglit outline of
the floor of the fourtJi, ventricle, and fi.xed in place. The suc-
ceeding plates were piled with reference to these two guides
and the plates already piled, and each plate as it was put in
proper position was fused with the plates already fixed.

The outline of the nucleus dentatus is very definite and
easily traced. Tlie capsule or Vleiss (Stilling) on the out-
side and tlie cor.' or llarkkern on the inside are both medul-
latcd and take the stain, thus distinctly limiting the yellow
mass of cells composing the nucleus. The drawings could be
very accurately made. In attempting to outline the accessory

TiXU &.ii\
N\[ai. Nuoa.m.

Fig. 1. — Transverse section of medulla and cerebellum (after Sabin, J. H. H. B., No. 81, December, 1897, Fig. 3.) Section at
level of uucleus of glossopliaryngeus and vagus nerves. Section also passes througli upper part of the dentate nucleus and
accessory nuclei. Long axis of nucleus is seen to form an acute augle, with the median Hue (formed by extension dorsally of the
raphe bisecting the 4th ventricle aud the cerebellum), with the augle openiug toward the medulla. Dorsolateral surface of dentate
nucleus is parallel to the surface of cerebellum. Corpus restiforme is seen to cover this surface. The accessory uuclei appear
separated and broken up by the white meduUated fibres. Variatious in thickness aud foldings of walls of the dentate uucleus
also well shown. Ililus ojiens medial- and ventralwards.

(2) the outline of the floor of the fourth ventricle which con-
trolled the dorsoventral curve. In the sagittal series the
section passing through this central point in the floor of the
fourth ventricle was selected and an outline of the longitu-
dinal curve of the floor was made. A flat surface having one
straight edge was then obtained. This edge corresponded to
the median line. To this edge was attached .the outline of
the floor of the fourth ventricle, already described, at the
proper angle corresponding to the angle at which the sections
were cut. With these two guides fixed the plate corresponding

nuclei, however, one meets with a real difficulty. This applies
particularly to the nucleus globosus and the nucleus of the
roof. The nucleus globosus instead of forming one mass of
gray matter is made up of several irregular groups of cells
separated by deeply stained meduUated fibres belonging to
the fibre systems of this region. These separate groups arc
clearly limited with a magnification of twenty diameters, but
when studied under higher powers one finds cells evidently
belonging to these groups scattered among the dense network
of deeply stained fibres. In studying the nucleus globosus

Apbil-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

153

through several consecutive sections under high jjowers one
gets the impression tiiat the separate groups seen with a
magnification of twenty diameters really form one nucleus;
that this lai'ge mass of cells is separated into groups by the
white fibres plunging directly through the nucleus; and this
impression is further strengthened by noting the cells scat-
tered among the fibres, included as it were by the bands of
white fibres.

In outlining the nucleus of the roof one meets \\itli the
same difficulty. In going over these two nuclei with a high
power to correct the drawings for transference to wax I had
to include the scattered cells referred to. I did this by
making the nuclei solid, not attempting to indicate the space
occupied by the fibres.

One other point is to be noted. The so-called accessory
nuclei, i. e. N. emboliformis, N. globosus and nucleus of the
roof, are usually described and figiired as entirely separate
and distinct cell-mass. In this series of sections of the new-
born babe, with the exception of the N. emboliformis, it has
been difficult, indeed impossible, at certain levels, to separate
these nuclei. The N. emboliformis forms a perfectly definite
cell-group, in the lower (distal) sections, appearing as a thin,
tongue-like ribbon of cells almost entirely occluding the liilus
of the corpus dentatum. Sections at the level of the middle
of the nucleus show it changing its shape, suddenly becom-
ing thicker and shorter, but clearly separated from the corpus
dentatum on one side and the nucleus globosus on the other
side by thin, deeply stained bands of white fibres. The
nucleus globosus also appears as a definitely limited and
separate group of cells in the lower (distal) sections, appear-
ing in sections a little above the beginning of the hilus of the
corpus dentatum as a small oval area of gray matter. At a
higher (proximal) level this oval mass is divided, as already
indicated. At the highest levels it is not to be separated
from the nucleus of the roof.

Corpus Dentatum. — It is embedded in the cerebellar hem-
isphere "like a peach stone" (Stilling). The distal end lies
more deeply buried in the white substance; the proximal end
approaches closely to the roof of the fourth ventricle, from
which it is separated by a thin ribbon of white siibstance.
Horizontal sections of the nucleus, as pointed out by Ober-
steiner, do not show the greatest diameter of the nucleus.
This appears in sagittal sections.

The dimensions of the model of dentate nucleus are as
follows:

1. Proximo-distal (sagittal), ID.Scin.

3. Mesolateral, (iu axis of nucleus ami nut at riglit angles to median
line), 19.4 cm.

.3. Dorsolateral, (perpendicular to mesolateral axis), 7.8 cm.

Remembering that the longest mesolateral diameter forms
an acute angle with the median line with the angle opening
ventralwards one will understand the measurements given.

The nucleus dentatus is really a hollow shell or sac with
its long axis directed antero-posteriorly (proximo-distally).
This shell is flattened dorsoventrally or at right angles to its
mesolateral diameter. The walls, which vary in thickness

from 0.3 to 0.5 mm., are thrown into numerous folds also
varying in number and size in different parts of the nucleus.
The folding of the walls gives to the svirface an appearance
not unlike the surface of the cerebral hemispheres or to the
gyri and sulci of the inferior olive. The shell of gray matter
is not closed but freely opens above (proximally), while the
ventral and mesial walls are incomplete in the anterior (proxi-
mal) two-thirds of the nucleus. This opening in the walls
forming the so-called hilus — hilus corporis dentati — looks
median-, ventral- and cerebralwards. In the distal one-third
of the nucleus the walls are complete and in transverse sec-
tions appear as oval closed rings or ring of gray matter.

The hilus in the more distal sections opens directly median-
wards; in sections at a higher level (cerebralwards) the open-
ing increases rapidly in size, the ventral wall becoming less
complete, while the dorsal wall forms a complete covering.
As a result of this progressive shortening of the ventromesial
wall the hilus comes to open wider and wider ventralwards.
This direction is further emphasized by the relation of the
nucleus emboliformis. In the most distal sections lying
within the mouth of the hilus it is in very close relation with
the dorsolateral border, indeed in the distal sections it may
be considered as a continuation of the dorsolateral surface on
to the mesial surface, being separated by a very thin band of
white fibres. This relation continues throughout the entire
length of the nucleus, there being only a thin space of sepa-
ration through which pass the most dorsal fibres escaping
from the Markkern of the nucleus dentatus.

In addition, the dentate nucleus presents for description
two surfaces, (1) dorsolateral, and (3) ventromesial; and four
borders, (1) mesial, (2) lateral, (3) proximal, and (4) distal.

Dorsolateral Surface, — This is the largest surface of the
nucleus (Fig. 2). It is irregularly quadrilateral in shape
and lies parallel to the surface of the cerebellar hemisphere.
The lateral and antero-posterior (proximo-distal) curves are
slight, the surface being quite flat. In this connection it is
interesting to note that a portion of the corpus restiforme lies
over this surface of the nucleus, forming a shell enclosing
the dorsolateral surface. This surface terminates mesially by
a sharp thin border in its upper (proximal) two-thirds, by a
rounded mesial border in its lower (distal) one-third. Later-
ally it is limited by the thicker, irregular and rounded lateral"
border. The proximal border also thin forms with the
median line an obtuse angle opening spinalwards. The distal
border is parallel to the proximal, is thick, rounded and is
broken into by deep sulci. By reference to Fig. 2 it will be
seen that the lowest sections of the nucleus includes only the
mesial- portion of this border.

The dorsolateral surface is traversed by five parallel deep
fissures, which run parallel to the long axis of the nucleus.
Beginning with median line these may be designated as
A, B, C, D and E. These fissures divide the surface into
six columns or gyri. Besides these five primary fissures there
are five secondary sulci, which are shallower and incompletely
divide the primary columns or gyri into secondary gyri. By
reference to Fig. 2 the following jioints will be noted: Fissure

154

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-122-133.

A is parallel to the mesial border, it is relatively deep and
its corresponding gyrus on the inner surface of the nnelens
looks lateralward (Fig. 3). The proximal end of fissure A
curves laterall)'. Fissures B and C present three curves, the
pro.ximal and distal with convexities pointing mesially, the
middle vi'ith convexity laterally. Fissure C is incomplete, its
proximal end not reaching the proximal border. Fissures
D and E form acute angles with fissure C with their proximal
ends pointing obliquely medialwards. It will also be noted
that the distal extremities of the columns or gyri are larger,
thicker and divided by extension on to this surface of the
fissures from the ventromesial surface. The deep fissures of
the ventromesial surface alternate with the fissures on the
dorsolateral surface. An exce])tion to this is in fissure D,
which is really an extension on to the dorsolateral surface of
the lateral fissure of the ventromesial surface. There is no
evidence of distinct lol)ulation visible on this surface.

The secondary sulci are limited chiefly to the three gyri
nearest the median line. In other words, the folding of the
dorsal wall of the nucleus is greatest nearer the mesial and
proximal borders; it is thickest nearer tlie lateral and distal
borders.

Ventrolateral Surface. — This surface is incomplete in its
upper two-thirds. It difi'ers markedly from the dorsolateral
surface. It presents two deep fissures radiating from a point
near the hilus about the level of the middle point of the
nucleus. These fissures may be designated as (1) internal
and (2) lateral. AVithin the internal fissure and nearly cov-
ered over by its projecting edges is a gyrus, broad at its base
(distal end) and tapering above, becoming lost in the most
proximal part- of the fissure. This gyrus, partly concealed
within the internal fissure, divides thi^ fissure into two, both
of which extend so as to appear on the dorsolateral surface.
These two fissures, internal and lateral, of the ventromesial
surface, divide this surface into three lobes, (1) internal, (3)
median, and (3) lateral. The internal is the smallest and
continues below the hilus on to the mesial border, being
distinctly marked off from this border by a shallow s\ilcus.
This lobe is broad at its proximal end, tapering off distally.
The median lobe, broad at its base — distal end — narrows to-
ward the point of divergence of the two fissures, internal
and lateral. The internal and median lobes form the most
distal part of the nucleus as viewed from its ventral aspect.
They slope with a considerable curve to meet the almost
perpendicular dorsolateral surface. They present no secon-
dary sulci.

The lateral lobe is the largest. It forms the lateral border
and extends on to both dorsolateral and ventromesial sur-
faces. On the former it lies lateral to fissure L\ while on
the latter it is limited mesially by the lateral fissure. This
lobe is most irregular in outline, is broken up by numerous
depressions and several secondary sulci. One of these sulci,
more conspicuous than the others, runs parallel to the upper
two-thirds of the lateral border.

The upper two-thirds of the ventromesial border is incom-
plete; the margin is very irregular as will Ijost be understood

by reference to Fig. 3. In general, it may be said that this
surface, as compared with the dorsolateral, presents (1) deeper
fissures, which give the appearance of lobulation, (3) thicker
walls, and (3) fewer foldings of the walls.

The proximal end of the nucleus being open this border
is limited to the thin edge of the dorsolateral surface, and
the very small part of the ventromesial surface. This border
slants obliquely spinal- and medianwards. The other bor-
ders have been referred to in describing the surfaces and the
hilus.

llie Accessory Nuclei. — The form and outline of the acces-
sory nuclei, i. e. the nucleus emboliformis, nucleus globosus
and nucleus of the roof, have been already referred to.
Figs. 5, 0 and 7 show these nuclei in relation to the dentate
nucleus. In Figs. V, and 7 the nucleus embnlifurmis is seen as
a long thin sheet of gray matter separated from the dorso-
lateral surface of the nucleus dentatus by a narrow space
already described. Its most distal end nearly occludes the
hilus corporis dentati (I'ig. 7), while proximally it changes
its form, becoming thicker and shorter, encroaching less on
the hilus. It will also Ije noted (Fig. 5) that its axis changes;
at first running dorsoventrally in its distal extremity, it comes
to lie more latei'ally in its proximal ]iart. corresponding in
direction with the dorsolateral wall of the dentate nucleus.
This nucleus is practically sc])arate throughout its entire
length, being the most definitely outlined of the accessory
nuclei.

The nucleus globosus (Fig. 5) is also seen as a distinct
oval mass of gray matter in its distal ]iortion, beginning a
little above the appearance of the hilus. In its proximal end
this nucleus is represented as fused willi the nucleus of the
roof (I'igs. 5 and 1).

The nucleus of the roof appears in the reconstruction as
a large irregular mass, distinct in its distal portion, becoming
fused with the nucleus globosus in its proxinuil portion. The
outlines of this nucleus are indefinite in this series, its ven-
tral surface being in very close relation with the gray matter
of the roof of the fourth ventricle.

DESCRIPTION OF PLATES XXIX-XXX.

Fig. 2. — View of dorsolateral surface of model of N. dentatus.
Proximal end corresponds to top of figure; median line is to left. J/,
mesial border; T, lateral border; ,1, B, C, J), Ji, are placed over
primary fissures; n, b, i; d, e, over secondary sulci; /, is extension on
to dorsolateral surface of tUe internal fissure of the ventromesial
surface.

Fio. 3. — View of ventromesial surface of model of N. dentatus.
Median line to rii;lit. 7, internal fissure ; L, lateral fissure ; i, internal
lobe; i/i, median lobe; I, lateral lobe; H, bilus.

Fig. 4. — View of mesial border of same at right angles to median
line. Relations of hilus to dorsolateral and ventromesial walls are
shown. Distally the hilus is narrow, increasin;;- rapidly as one passes
cerebralwards.

Fig. .5. — View of mesial border of N. dentatus with accessory nuclei
in place.

S, nucleus emboliformis; O, nucleus globosus; S, nucleus of the
roof; o, narrow space through which escapes UK^st dorsal fibres from
MarkUern.

Fig. 6. — View of dorsolateral surface of same. Legend as in Figs.
3 and .5.

Fig. " View of ventromesial surface of same. Legend as in Figs.

3 ami 5.

THE JOHNS HOPKINS HOSPITAL BULLETIN. APRIL-MAY-JUNE. 1901.

PLATE XXIX.

Fig. 3.

Fig. 4.

THE JOHNS HOPKINS HOSPITAL BULLETIN. APRIL-MAY-JUNE, 1901.

PLATE XXX.

Fig. a.

Fig. 6.

Fig. 7.

Ai>i!il-May-Juxe, 1901.

JOHNS HOPKINS HOSPITAL BULLETIN.

155

USK OF THE 3IATKIUAL OF TIIF DISSECTIXd ROOM FOI! SCIENTIFIC ITRFOSES.

By C.'iiAJti.ES i;i>--^i:i.i. Bardeen, M. D.,
A.ssoi'idh' ill Analiiiitij. J</liii^ IloiiIiHis I ' iii rrrsili/.

L'liseiiln'i'g. in ;i ruL-eiit iirticlr.' Ii;is failed atli'iitioii to ihe
oj]|i(irtunitic>.s that the disseeting room offers I'or seientilic
investiuation. He gives an interesting siunniarv of the vari-
ous atteni]its that have been made to take advantage' of tlv s.'
ojiportnnities. and calls |iartieular attention to the records ob-
tained by Selnvalbe at Strassburg. by C'nuningham at Dublin,
and bv tlie Anntonncal Society of (ireat l'>ritaiii and Ireland.

Fig. I.

It has seemed In me that the mctlinds employed In utilize
the material of the dissecting room ami the work of the
students for scientific purjioses in Professor MalTs lab(jratory
at the Johns Ilojikins TTniversity, iialtimore, uuiy ])rove ol'
interest, ]iossibly id' value, to those engaged rl.-c\vliere in
anatomical instruction.

The immense amount of study that luis been given to thi'
structure (d' the human b<idy during the last foui- ci'uturies
reiulers it nnli]<ely that tlu' stiulent's initrained eye and hand
could be utilized to advantage in a search for unrecorde 1

' Mi>r|'li(iluu:isr'lK's .Talnhiich, isii.i

facts of gross structure even if tinu' [lermitted him to delve
in those little nooks and corners where the records are still
incomjilete. The very considerable amount of variation,
howevei'. which the individual liodies present in the structure,
form and relatioiislii])s <>( their various organs, olfeis a rich
field for cxdtivation.

Since tlie time of ])arwiu much attention has been given
to the study of variations in plants and animals. The greater
part of the attenticn. however, has been given to external
features, to variation in size, color, and e-xternal fmni. Few
studies have Ijcen made of the frequency of variation in the
internal organs. Yet ]irobably the body of no animal is
more suited to this study than that of man and none is
studied with care by so great a number of indi\iduals each
year.

Until couiparali\ely recently the variations brought to
light by the dissector have lieen recorded only when of an
unusual nature. These observations, however, have been so
numerous that we may assume that most of the variations
likely to be brought to light have previously been recorded.
While the limits of variation of the various organs of the
liody are thus fairly well understood, the fre(|ueucv of varia-
tions has Ijeen determined but for few organs and for them
only incom]iletely. The true "'normal'" or "most usual"
is unkniiwn. lleiile. in his anatomy, pictured tlud as nnriual
which his experience led him to think the most usual. Most
of the other leading anatomists have done likewise. No two
books, otlier than comjulations from siuular scuii-ces, give the
same account of the normal form of the various organs. The
great ojijiortunity whicli the dissecting room olfers is that
of determining the curve of frequency of the various {'(u-ms
presented by bodily structures, and thus to make the normal
a question of measurement rather than one of jiidguumt.
To render this jjossible. accni-ate records of the ccinditions
found in each body must be uuide. of such a nature that they
may be afterwards compared and reduced to tables.

The method u( rec(U-d thus becomes a question of para-
mount importance.

In the Anatomical I/aljoratory at the Johns Hopkins Hni-
versity the first attemjits at making systematic records of
conditions of structure revealed at the dissecting table were
begun in tlu' fall <d' IS'i:.. It was determined to make a
study (d' the variatiiuis in the <list ributioii of tlie ei'auial and
s]iiiial nerves, especial attention lieiiig paid to the cervico-
iu-achial and the lumbosacral plexuses. .\l the instigation of
Professor JIall, Dr. .V. W. h'lting. at that time Assistant in
Anatomy, prepared three record-charts, one for tiie nerves
of the head, one for the nerves of the neck, arm and upper
half of the thorax, and one feir the lower half id' the body.
On these charts a iceord v\'as made (d' the sex. color, and aiie

150

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 131-123-123.

as well as of the nerve distrilmtion in the body of tlie indi-
vidual dissected. The seheme for recording the latter was
as follows. On separate .successive lines the numerical desig-
nation of a given cranial oi- spinal nerve was placed, followed
hy a list of the names of tlie nerves (o which the given main
nerve li'unk was assumed to conti'ihnte. In the preparation
of this table the standai'd anatomies were consulted. A few

The student.s were requested to compare carefully the
nerves in the part dissected witli tlu' outline scheme, to
unileiliuc Ihe names of those nerves wliich were found to
coi'rcspond willi the sclu'me. to cross out the names of the
nerves whicli did not thus correspond, and to insert these
names in llic prii|iei- place. Complex conditions, such for
instance as ai'c fmind in the cervicohrachial and the lundjo-

Fui.

lines from the " ( 'cr\ico1ii-acliial Chart" may sulllce to make
clear the general nature of this scheme:

C. VI. I'oST-liU. AnT-BU. _roST-TI10UAClC. SUISCI.AVIUS. SUPiiA-

scAP. Com. C. VII.

C VII- PosT-Bit. AsT-uit. — Extant TiioKAcic. Com-post. coud.
Outer Cord. Musc-cut. — Vor-brai-h. Biecps. hr-ant. Ant. Post.
OuTEii-ilEAP-MEDiAN. — Aiit-inUros. raliii-cut. Tliinnb-hr. .5 DiijitaU.

C. VIII. PosT-nu. AxT-mt. Inner Cord. Post. Cord. Sii!-
SCAPS. — Upjjir. Middle. Lcwrr. CiiicuiiFLES.. — Siip. Inf. Art. Muse.
Spiral. — Musi: Int-eut. Ert-np-ciit-hr. A'.rt-lou<-cut-bi: Mnsc. Radial. —
Exl-bi: Inl-bi-.t. 4. PoST-lNTEiios. — .l/"sr. .1/7. CoJi. 1). I.

saci'al plexuses, woe illustraled liy diagrams drawn on the
backs of the charts.

These outline schemes were well arranged and Ihem'elically
should have workeil well, '^'ei they did not prove a success
in the hands of the students. The suggestion induced by
print seemed continually to lead the student into reading
the scheme into his "]>art." The task of verifying the
charts thns became a severe one. Another diltlculty came
from the fact tluit names can mean little so long as the
'■ mirmal " is unknown. While the larger nerves arc so con-
stant in position that the names cin'reut in the text-books

Ai'1!1l-May-June, 1901.

JOHNS HOPKINS HOSPITAL BULLETIN.

157

could be used without confusion it was I'diiud that many of
the smaller nerves could he definitely rcennlcil nniy l)y attach-
iufj a sjieeial definition to the name, 'i'lic iliohi/iiof/aalric
and the ijcnUocrural nerves may lie iiiciil inncd as examples.
The value of these earlier charts lies rather in tlie ilhistrative
diagrams of the plexuses placed on llie liaiks of the charts
than ill the records made on the tabulation seiiemes.

Ill the fall of 1897 I undertook the iiniiiediaie sii|iervisiiin
of these records. I discarded In a coiisidiTablc cxlcnt the
use (if thi- ]iriiited schemes. The students were ciicouraLjed
to record the distribution of the nerves by making free-hand

of tlie front of liie thigh; one for the sacral plexus; one for
the })erineuiii; one for tlie back of the thigh, etc., in all 36
charts.'. Separate charts are used for the riglit and left sides
(if the hoily.

In these diagrams tlie bdiu'S and the surface (lullinr of the
body after the remciva] (if the skin and tlie superHcial fascia
are indiealed by hue Hues |ii-inled in brown iii1<. The scale
of the charts varies I'l-diii niir-balf to full bl'e size, according
to the I'egioii to bi' charted. In this way the general average
jirojiorf ions of tlie vari(nis parts of tlie body are furnished
the student. JMarked variations from these proportions can

xrHSji

■ :.:-.M-N S/.-

Fic. ■.',.

diagrammatic sketclies to illustrate the cdndilinns found in
the parts dissected. "Many of thi' drawings ihii,~ made were
well executed. Yet few of the stmh'Uts are snnicieidiy skill-
ful draughtsmen to make even these simple sketches without
a, great expenditure of time. I therefore devised a si't ol'
simple outline diagrams on which the nerve distribution can
lie recorded. These diagrams are arranged for llu! various
parts of the body. Thus there is one for tlir alHldiin'ii, which
can hi> used cither for the nerves of the alMldiniiial walls cr
for the liiiiihai' plexus (see Figs. 1-3); anotbci' fcir the nerves

readily be imlicaliil by changing the faint outlines of the
skeletal scheme. .Vflci' removing the skin from a given part
of the body the stiiclcnl draws on the appropriate diagram the
course (if the superficial nerves as lie finds them running in
the fas<'ia. When the muscles have been dissected out the
ner\i.' supply of the various muscles is charted. Muscles and
other slructures are drawn in to show the g<'neral relations of

- ■flii'si- cliiii-ts liMvr lirrn |.n li I i sliL'd ill iniiiiplili-t fonii; •' Oiitliiii'. lli'cnra
Charts." ■flii.' J.iiins lloiikins Press, Baltimore, IHUO.

158

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. ] 31-12-2-123.

llic iKTvef!. The best ix-fovd.s have been obtaiiicrl when the
student luis attempted to record only a few siiiipli' iimditidns
nil a sinnh' chart. Tims in cliartini;- the nerves id' llir rnnil
uT the tlii.^Ii separate eliarts are used to record the ihslrilui-

J./" MS/,„

Fig. 4.

tioii io tile siiiii)rliis rnusck^, to tlie redii-^ muscle, to tlie dei'p
c.i:teiisur muscles, to the adductur lo)i(jii.s muscle and the
(jranlis. to the adductor lirevis muscle, and lo llu' addndur
iiiiiijims and rxleninl ohlurator muscles.

To illustrate the method of using these charts a few ex-

amples may be aiven. I'^ip. 1 I'cpresents the outline diafrram
used For the alMhuiicii and the lumbar region. Fip. 2 shows
the distribution oi the main ventral trunks of the abdinninnl
nerves as dissected out and recorded by two students, fiu. 3
represents the lumbar plexuses and the distribution of the
■' Ijorder nerves" found in the same subject. The lateral
branches of the abdoininal nerves are shown in auntlu'r chai't
(Fig. 4).

Of course one cannol hope to get from students the com-
])lete and accurate records which one could get by }iersonal
di.ssection. It is cnily rarely that perfectly satisfactory records
are ol)taiiied of (he [leripheral distribution of all the nei'ves.
On the other hand, it would be a physical impossibility by
personal dissection to get the same number of records in the
same si)ace of time. Mistakes are more likely to be those of
omission than of a jiositive nature. The student may destroy
some fine nerve twig before it has been seen by an instructor,
and thus it may csca])e record. The conditions that the
average student finds and records are, however, of great value.
Thus only may we ho])e to get that large number of records
frcun whiih a curve of frciiucncy may be detei'inined.

In aihlition to the oi.tline diagrams I have devised a simple
printed scheme for keeping record of the race, sex, age, size,
skeletal peculiarities and marked variations from the normal
in the various organs of the body. This latter set of records
is made out Ijy the instructor who verifies the charts.

The verification cjf (he charts is one of the most important
features of the undertaking. Without careful verification by
one man who gives his time in the dissecting romn mainly,
if not wholly, to this task the charts can be of little valu ■.

Active co-operation on the part of all the instructors and
of the students in the dissecting room is also essential.

The conditions which at iircsent prevail in our nu^dical
department render it also perhaps more than usually easy to
get the co-operation of the students in carrying out work of
this kind. The standards of admission to this school bring
us a much nuu-e highly trained class of students than thos.'
usually found entering the average American medical schocd.
On the other hand, the routine of a graded com-se, while
inferior as a method of education to that freedom of choice
which nuirks the German university, renders it much easier
to win the co-operation of the students in this work. The
number of students dissecting each year since the beginning
of the undertaking has averaged about one hundred.

ON THE DEVELOPMENT OF THE HUMAN DIAPHRAGM.

In a paper on the development of the human cadoni, pulj-
lislicd several years ago, I was not able to give a detailed
description of the separation of the body cavities from one

' Mull, Jour, of Morph., vol. la, 1897

By Fhanklix P. Mall,

Professiir of Aiiuloini/. Johns Hopl-ins UniveisUy.

another, because the specimens at my disposal did not include
all the necessary stages. For that study I used 19 human
embryos between 2 and 2-1 mm. long, in which various stages
of the development cf the body-cavities were shown, but a
number of the important stages were missing.

Ai-eil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

159

During the past three years the collection of human eui-
hryos in the anatomical laboratory has grown very rapidly
anil all the missing stages for the study of the formation of
the body-cavities have been supjilied. The following table
gives a list of these embryos. It will be seen from it that

TABLE OF E.MBRYOS.

Time

tJrL'atost

between tln'
be^innill;:'
or tbe la.-^t
period and

Direction

Ni).

lenji:th in
mm.

of the
seetion.

iin whom obtained.

the abortion.

XII

2.1

41 days

Transverse

Ellis, Elkton, Md.

CLXIV ...

3 . .5

MaoCalhmi,

Baltimore.

CXLVIII .

4.."

3S days

Hoen, Baltimore.

I.XXVI. ..

4.. 5

.Vliteliell, Cliieago.

LXXX ...

Brauham,

Baltimore.

CXXXVI .

.56 days

Sagittal

Campbell,

Halifax, N. S.

CXVI

6.5

5.5 days

Ryan,

SpringHeld, 111.

53 days

Transverse

C. O. Miller,

Baltimore.

CXIII

Sagittal

Gray, Washington.

CLXIII ..

5 weeks

Transverse

Lamb, Washington.

CXIV ....

Sagittal

Gray, Washington.

CIX

Transverse

Cusliing,

Baltimore.

CXLIV ...

Sagittal

Watson,

Baltimore.

XLiir ....

liookei',

Baltimore.

LXXIV...

li>

Transverse

Irving Miller,

Baltimore.

the series from 2 mm. upward is very complrir with the e.\-
ception of stages between 11 and 14 mm. long. Fortunately,
the missing stages are not important. All the embryos given
in this talile are practically perfect, the imperfect ones liaving
been excluded. The present study is based u|hiii !•") embryos,
only 3 of which are included in the 19 specimens considered
ill (he earlier communication.

Il has often been stated thai Ihe development of lln
diaiihrngin, i'S]i('cial]y in the Inmian embryo, is one ol'
III!' iiiiisl (liHiciill |ii'ol)lenis of embryology, fiarty because
(if the dilliciilty ill obtaining the iiecessaiy s|ii'ciiiii'ns ami
partly heeaiisi' there are no fixed points rioni whiih In enleu-
late. Ill its (h'\i'loi)ment the wliole ilia|ilii'aeiii wiuiilers rrom
the head (o the abdomen, passing Ijy as well as iiinilil'vino
the structures and organs along the way. Sn. while vmi
Baer recognized that the diapjliragm wandered in its develop-
ment, picking up its nerve in so doing, a fairly clear pic tiiiv
of the whole process was not given until Ilis studied eaicfiilh-
the develo|iiiieiit of the iieelc, heart, lungs and intestine. In
his studies His recognized the Aiihiijc of the diaiihiagin in a
mass of tissue located with thi' liearl ainniiesl struct iiics
lieloneing to the head and eonlaining within it the \'eiiis to
the heart as well as the An/age of the liver, 'i'his mass of
tissue ITis termed tbe septum transversuni. Ilis's studies

were made ui)on the human embryo, mainly by the method of
reconstruction, and .shortly after they were published Uskow
made a very careful study of the further growth of the septum
transversuni. Uskow recognized the great importance of two
additional structures in the formation of the pericardium
and adult dia])hragm from the septum transversum; these he
termed the iileuro- pericardial memhranc, containing the
phrenic nerve, and the pillars which form the dorsal ends of
the diaphragm. The pillars of Uskow have been termed the
plcuro-periioncal memhranes by Brachet, and as the lattiT lei'in
is more appropriate than the former I shall employ it in the
present paper.

j\ly own studies show that the pleuro-pericardial and pleuro-
peritoueal membranes arise from a common structure, which
extends from the lobe of the liver along the dorsal wall of the
ductus Cuvieri to the dorsal attachment of the mesocardium.
Ijater this structure grows towards the head to complete
the jileuro-pericardial memlirane and then towards the tail
to complete the pleuro-peritoneal mendirane. This stiiietnre,
which I shall term the pulmonary ridge, is located in the
sagittal plane of the body-cavity with cephalic and eandal
horns on its dorsal side. The ductus Cuvieri lies between
these horns (Fig. 29).

The purpose of this paper is to follow carefnlly the fate
of the septum transversum and the origin and fate of the
liulmonary ridge in the human embryo. In so doing il is
of course necessary to consider the division of the body-cavity
into the pericardial, pleural and peritoneal cavities. Accord-
ing to liis, the body-cavity in early embryos is divided into
the Parietallwhle and Bumpflwhlen. The communicati-ou be-
tween these spaces he has also termed the recessus parietalis.
The parietal cavity from its earliest appearance contains the
heart and is destined to form the pericardial cavity. T shall
term it the pericardial coelom. A portion of the recessus
]iarietalis forms the pleural cavity; it surnninds the lung
bnd throughiuit its development and I shall term it the
pleural eoeloin. The revnainder of the recessus |iai-ielalis
to the origin of the liver has developed in it the liver and
stomach; this is added to the general peritoneal cavity and I
sliall term it the periloneal cculom. In the early embryos
the whole eieloni lies far out of place; in F.mbryo XII nearly
Ihe entire cadoin lies in the region of the head and iieek ami
in the further develn|inieut of these parts the cadom with Ihe
surrounding organs wanders away from the head to its |ier-
manent location. .\s long as the serous cavities arising from
the codom are in tlu' process of wandering and are mil fnlly
separated from one another I shall term them ]ileuial, peri-
cardial and peritoneal coelom: when they are fnlly established
I shall call tlieiii cavities.

Ill Embryo .\li, l''ig. 1, the cceloni of the embryo forms a
fi'ee s|iaee eueiicling the heart and extending on either side
of the body over the om|ihalo-mesenterie veins to the root of
till' nmhilieal vesicle. This canal of commuuieation has ile-
\ elo|ieil wil hill il t he lung, stomaeh and li\'er, nml I hroiighoni
its eai'lier ile\elo|iiiienl it measures in length ahoiit one-fourth
of thai of Ihe hoilv (iMiibrvos XII, (IXLVIII, LXXVI,

IGO

JOHNS HOPKINS HOSPITAL BULLETIN.

[JJos. 121-122-123.

LXXX,, II and C'J.Xlll). The appearam-i' of the lun,;;- and
liver marks the sul)divit;ion of the (•(I'loni iiiio the jileural and
jjeritoiieal cadojii. W'ilh tlie dexeldpnient of tlie liver, limy
and stomacli tlie e(eliini einilainiiiL;- them gradually dili:te>'
until the emhryo is ahout !• nun. long, when the canal
evaginate.s, so to speak, and Inrns the liver and stcnnaeh
ont into the general pei'iloiienl cavity. The Wolllian liody,
which (iniqiiod the dorsal A\all of this canal, gradnally
degenerates and the Inng takes its place. From these state-
ments it is readily inferred that the canal extending from the
pericardial cceloni, Ilis's recessns parietalis. gives rise to the
]ilenral codoni on its dorsal side and to the peritoneal cielom
on its ventral side. The line of division is formed hy the
plenro-jieritoneal memlirane extending from tlic ductus
( 'uvieri to the adrenal.

Ar.

<•«

Fig. 1. — Pniiilc recmistnictiou of tliu eiiibryo 2.1 mm. loug. No. XII
X liT times; m/i, amnion; iii\ optic vesicle; nc, auditory; vesicle hc,
umbilical vesicle; h, lieart ; I'om, omi>lialo-meseuteric vein; mr, sep-
tum trausversum ; Oj, tUird occipital myotome; t'j, eiglitli cervical
myotome.

The earliest emhryo in my collection in which the sejitum
transversnm is well formed is No. XII, 2.1 mm. long, and
about two weeks old." The specimen is very valuable for the
.study of the beginning of so many structures that it also
Ijecomes a good starting [loinl fur I lie study of the dcNclnp-
ment of the diaphragm.

Figs. 1 and 2 give the external fcuin and oulline id' Ihe
neural tube and alimentary canal drawn from a reconstruc-
tion. It is seen that the c(el(nH sends two canals into the

■-' Ditfereut pictures of this emliryo will be fimiul in the; .ImiiiiMl of
Morpli., vol. 13; Ilis's Arcliiv, IS'.lT; .lolins Iloplviiis Hospital Hnllctin,
IS'.IS; and the Welch Festschrift, .lohus llopkius Hospital Heports,
vol. '.I.

head on either side of the neck which comniuiiicate with each
dlhei- ill tile immediate neighliorhood of Ihi' nKUith. This
U-slia|ied canal is sepaialed fidiii the exocielom on its ventral
side by a Ijridge of inesodermal tissue connecting the umbili-
cal vesicle with tlij embryo at the juncture of the head with
the aiimion. It follows that this liridge of mesodernial tissue,
the sepliim transversuni, is also U-shajied, as is shown in
l-'igs. 1 an<l 2, iST and ilA//. ll forms a jiortion of the ventral
wall of the pericardial cadom and sn]iports the omphalo-
mesenteric and nmliilical veins. Sections of it are shown in
Figs. 3, 4 and 5, which are from three sections through the
head end of this embryo in the neighborhood of the first
cervical myotome. The Aiilage of the liver is shown in
Fig. t. which is located in this stage in a region belonging to
the head.

**>>„

Fui. 2. — Parlial dissection of the reconstruetiou of the embryo 2.1
mm. long. No. XII x 37 times; dm, amnion; m, mouth; Hi', Br",
lirst and second braneliial pockets; /, thyroid; p, pericardial coelom ;
.■i^ septum transversuni ; I, liver; kc, nQibilical vesicle; /«•, neurenteric
canal.

Figs. G to 9 are from an emhryo (CLXIV) slightly more
advanced in development than No. XII. The embryo is from
an ovum measuring 1 T x 17x111 mm., found in the uterus
at an autop.sy. W'lii'ii the uterus was cut o])en the knife
entered the ovum and |Hissil)ly distorted tlie emliryo, for when
it came into my hands it was foimd that the emliryo was
lloating in the cavity nf Ihe ovum Imt il was still adherent
to its walls. This mechanical injury iindoiilitedly caused the
body nf the embryo to straighten and at the attachment of
the iiiiibilical vesicle the body <if the embryo is bent towards
the \entral side, as is the case in a number of the His em-
bryos (for instance, I'>H). The ventral wall over the heart,
was also slightly torn. The entire uterus and ovum had been

ArRIL-MAY-JuXE, 1901.

JOHNS HOPKINS HOSPITAL BULLETIN.

161

liTcservod on ice fni' 2[ linurs, mid wlicn it was jiiven io iiie
Iiy l»r. ^lacCalhiiii tiic i.'iitiic s|MMiiiic'i\ was iila<Til in sti-on>^
formalin. The si't-tioiis dl' tlic ciiilirvo sliiiw thai the tissuesi
ore slightly iiiaceiTited Imt in i^cncral they arc well ]ire?orv<'(l.
The spinal ecinl is (■l(ise<l ihnui.uhont its extent Iml thi'
iiourcniore is still open. The thyi'oiil iiland. ii]i(ic and otic

Fig. o. — Section tlirougU tlic lirad <if tlie embryo '2.1 mm. loiii;-. No.
XII X 50 times; rue, coelom ; /</i, pluiryiix ; /, liver; xl, seiitum
transversura ; irr, umliilic.il vesicle.

vesicles, heart and veins, are but slightly more developed than
ill N^o. XII. If this enihryo were curled up as No. XII it
would measure froni 2.5 to 3 mm., whih' if the two had lunn
hardened in the same way (Xo. \ll was hardciicil in ahohdl)
they would ])rolialily measure alike.

Fig. 4, — Section tlnnnu'li tlie tliird occipital myotome of the cmhryo
2.1 mm. Ions. -"I mm. nearer llic lail tlian Fii;. 11 x .">(! times; (l.j,
tliirel occipital myotome ; c«c, coelom ; /■, vein ; .■</, septinn transvcrsnm ;
!, liver; pli, pharynx; "c, umbilical vesicle.

The figures given sliow the general relation as sei'ii in
I'lmliryo .Xll with e;u-h id' the st laict ui'cs hut slightly iuhaiii-ed.
The septum transversum is much the same as it is in .Xll,
while the pericardial co'lom is puslied more to the ventral
side of it and (he diverticidinii to tnini the liver is more
marked. The iindiilical vein has extended somewhat (Fig.
9) and the jugular vein has made its appearance (Fig. T).

The tissue of the septum transversum in the two embryos
is formed of irregular round cells, between which there are
numerous vessels, of irregular diameter, which commnnicate
freely with the veins to the heart.

The next stage of the develupment of the septum trans-

'A ' ' !'

3-^-c.

Coe ;'

■^vu

(-VOM

Fig. 5.— Section throusli the first cervical myotome of the embryo
:i.l mm. lonic, .'IS mm. nearer the tail than Fiir. 4 x .iO times ; f\ lirst
cervical myotome; toe coelom ; ;■», umbilical vein; ;"'/», omplialo-mes-
enterie vein; iiiiib, umbilical vesicle.

versnm is found iu an embryo 4.3 mm. long (CXLVII), ob-
tained from llr. Iloen.' The specimen is perfect and normal,
as it was obtained through uiechanic;il means. The entiro

(S^^-:^

Fig. (i. —Section throun-h the head of the embryo 3. .5 mm. long. No.
CLXIV X .'iO times; y</(, pharynx ; i«, bullius aortae ; cc/j/, ventricle.

ovum was hardened in S(i |ier cent alcohol shortly after it
was expelled from the uieiais. This of course fi.xed the
embryo in its natural shape, as was the case with No. XII.
iioth embryos are cnrved, but in the emliryo 4.3 mm. long
the lii-aiiehial region occupies relatively more space than it

'A photograph of this embryo is given in the Welch Festschrift.

1(52

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nds. 121-122-123.

does in the embryo 2.1 mm. long. In proportion to the
length of the embryo.? this distance h;is inerensed 3 times,
Tlie pericardial cfrlom has receded i'roni the head in |)r()]ior-
tion to the inerenso of the growth of the branchial arches.
In the emliryo 2.1 mm. long i\\v kead end of the |ici-ieardiai
crelom is oiiimsHe (he otic vesicle, while in the end)rvo 1.3

Fig. 7. — Section tlirdiiuli tlu' embryo o..5mm. loiiir. .14 mm. nciirur
the tail tb.au Fis;. 0 x ."'O t mcs ; p/i, jiljai-ynx; lui, auricle; rent, venfiicle;
.■it, septum tr.ansversum ; <;/, jugular vein ; /'», umbilical veiu.

mm. it is o])]iosite the first occipital myotome. The puint u\'
comnnmication between the peritoneal coelom (encircling the
liver) with the exococlom has also receded. In the embryo
2.1 mm. lung it is opposite the second cervical myotome; in
embryo 4.3 mm. long opposite the second tlioraeie myotome

Fig. S.— Section tlirougb the embryo S.6 mm. long, .'2 mm. nearer the
tail than Fig. 7 x .50 times ; I, liver; wiit, ventricle ;.«»■, siuus renuieus;
coc, coelom.

(compare Figs. 1 and lU). Ilis's embryo Lr (4.2 mm. Imig)
is intermediate between the t\V(i embryos just compaicil. In
Lr (see liis's Atlas, Pis. IX and XI | llie ]ierieardial. |ileural
and peritoneal creloni encircling tlie liver extends from tlie
first occipital myotome to the sixth cervical, and the omphalo-
mesenteric veins jirotrnde into these canals of the co'lmn.
The liver has extended into the septum transversnm but does
not yet encircle the omphalo-mesenteric veins as it does in

my embryo 4.3 mm. long. This detailed descri])tion is given
to show the fate of the ccelom ' of the hea<l and neck. It
gives rise to the pericardial and ]iit'ural cavities, and tliat por-
tion of the ]U'ritoneal cavity encircling tlie liver of (he adult.
Sections of the embryo 4.3 mm. lung ( Xo. C.XIjVIII.
Figs. 11 and 12) show the livei' sprouts growiiio' in all dii'cc-

FiG. 9. — Section through the embryo 3..'> mm. long, .is mm. nearer
the tail than Fig. S x .50 times; rvw, coelom; ii:l, intestine; rum,
(^mphaln-mcsenteric vein ; /■//, umlulical vein.

tious tlinuigli the sejitum transversum. encircling and ramify-
ing through the omphalo-mesenteric veins, making a condition
slightly in advance of that in Ilis's embryo Lr. The sections
of this embryo show clearly that the heart, lungs, liver and
li'Wer peritoneal cavity arise in tissues surrounded by that por-
tion of the cadom extending into the head in Embrvo XII,

Fig. 10. — Outline of the embryo 4.:! mm. long. No. CXI.VIII x 1.5
times. '',, first cervical myotome; r',, ei!?''t'' cervical myotome, 'llie
line imlieates tlie dii'ection of the sections.

Fig. 1. Fig. 11 is taken from a section through a plane cut-
ting the root of tlie arm and the otic vesicle, and can readily
lie placed in the outline, I'ig. 1(1. It is seen that the lung.--
arise wlicre the pericardial ecelom goes over into the pleural,
/. ('. high up in tlie region of the head. Immediately on the
dorsal side of them is the beginning of the lesser ]ieritoiieal

' Kopfbohle ; ITalsboble; I'arietallioblc ami recessus |i;n-iel:ilis.

Ai'hil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

163

cavity, and the intestinal tnbe struck in this section is the
stoniacli. All these stnietnrcs lie on the cephalic side of the
first cervical myotome. Projecting into the peritoneal ccelom,
encircling and penetrating the omphalo-mesenteric veins are
the projections of the liver. Figs. 11 and 13, L. The two lohes
rrai-h I'rom the tip of the Inngs ami the foramen of Winslow to
the point wliere the entodermal cells of the liver arise from

ryj)

Via. 11. — Section tlirougb the embryo 4.3 mm. Innsr x 2.5 times; T,,
lirst tlioracic myotome; C, C,, and (\, cervical myotomes; .s', stomacli ;
fti, brdnchus; /i, heart; (, thyroid; /<■•, pericardial cavity; I, liver;
/>, foramen of Winslow.

llic aliinentaiy canal, or in this ease the iluodcimm. The lobes
of the liver lie entirely within the canals of the coelom on
either side of the head. The caudal ends of these coelom
canals have migrated from opposite the second cervical myo-
tome ill Emliryo XII, Fig. 1, to opposite the second thoracic

.. ^T^

UV /

-'#^^

-5^)/,

L *

■-■/

Fig. 12.. — Section throush the embryo 4.:i mm. loun, .4 mm. deeper
than Fis;. 11 x 2.") times; /, thoracic myotomes; ;, intestine; /, liver;
/', ventricle; bii, bulb of the aorta; nm, amnion; iii\ umbilical vein.

myotome in Embryo CXLVIII, Fig. 10. It has moved to-
wards the tail eight segments, while the cephalic end of ilie
canal, the ]iericardial ccelom, has been kinked over to corre-
spond with the bending of the head, has dilated to correspond
with the growth of the heart, and has receded from the otic
vesicle to (lie extent of the gi'owlb of I he linincliial arches.
We have in this embryo the necessary stage to Imnte tlie
organs which arise in the neighborhood of tin; sepiiim tiaiW'

versnni, as well as to give the fate of the ccelom in their
immediate neighborhood.

A stage somewhat in advance of CXLVIII is ]A.\^M.
The embryo is slightly larger, measuring 4.5 mm. in greatest
length. It was obtained from the uterus 7 hours after death.
The entire ovum was placed immediately in aljsolute alcohol.

Fig. 13. — Section through the embryo i.n mm. long. No. LXXVI x
2.5 times; /'c, cardinal vein; l/jc, lesser peritoneal cavity; <lc, ductus
Cuvicri; xc, sinus vcnosus.

It was impossible to obtain a picture of the embryo before it
was cut. but the specimen proved to be an excellent one.
The direction of the sections is more nearly transverse than

Fig. 14 Section llirougli the embryo 4.5 mm. long, .il nnn. deeper

than Fig. IS x 25 times; we, cardinal vein; u, aorta; nnii. omphalo-
mesenteric vein; fii, umbilical vein; /i, heart.

in CXLVIII. In CXLVIII the neuropore is closed with
a thickening of the e|iidermis just over the point of closni'e;
the umbilical vein entei's the liver and its direct connection
with the ductus ('ii\ieri through the body wall is cut oil'.
In LXXVI the neiiid|ioic is completely closed and the eiiilii'yo
is somewhat lai'ger than hefore (compare Figs. i:i and I I
with II and 12); the umliilical vein, however, coiiiniiinieates
with I ill- (liictus Cuvieri tiirough the body-wall on the left

164

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-1^2-123.

side. This Ls an instaiifc nf rctardcil (li'vclii|inii'nt of a part,
as tlie left iimliilical vein t^liniild lia\r \alli^lu■d liy lliis time.
Fig. 13 gives a seel ion lliniiigli llie tdi-anien nf Winslow
imniediately on tlie caudal side (if tlie lung liuds. as shown
in a lateral view of the nuidel of the eniljvyo. Fig. 1-"). The

Fig. I.-

se]ituni transversuui and liver have increased in fpiantily. as
a e(nn|iarison of tlie dilVerent tigui'es will show. In tliis

Fig. 1G.

Figs. 1.5 .iiul Ifi. — Riirlit aud left views o( ,t roconst ruction of the
embryo 4.. T mm. long x 2n times; n, aort.i ; ph, pli;ir\ii\ ; Im, hulbus
aort;e ; me, coelom ; /), purieardiiil coeloin ; /, lung'; li, liver; Wb,
Wolffian body ; ■«, stomach ; ./>, foramen of Winslow ; .«■, sinus veuosus ;
"I, septum transversum.

stage we have the extreme bending of the head, which throws
'the heart to its most ventral ])oint with the septum trans-
versum aliout parallel witli long axis of the embryo. The

PC DC

Fig. it. — Lateral view of the reconstruction of an ciuliryo .5 mm.
long. No. LXXX x 17 times; I, hinir; li, liver; s, stomach: dc,
ductns Cnvieri ; pr, pericardial coelom which communicates fully with
pi euro- peritonea I coelom.

position of the heart, lungs, liver and their relation to the
cadom is much the same as in the younger embryo with the

exception of the lesser ]ieritoiieal cavity, which is now more
to the i-audid side i.if the limits.

While ill the embryo 4..'! uini. long llie niyoiomes were well
formed and hollow, in the iMuliryo 4..") they are solid and
contain embrvonic muscle ii'nes. The dorsal ganglia are also

._DC

Fin. Its. — Section through the nceU and heart of embryo LXXX x
2.T times; '',, fourth cervical nerve: iv, cardinal vein; </(-, ductus Cuvieri;
Of, oesoi>liagus ; //-, ti'achea : .sr, sinus renniens.

more developed. In the I'lubiyos ."i mm. long (LXXX and
('.XXXVI) the myotomes are still further difTerentiated with
nerve tiimks. composed of lioth dorsal and ventral roots,
which are growing into the body-walls of the embryo. Figs.
IT-.'O give the general form of this embryo, in reconstruction

Fig. 111. (Section through embryo LXXX .:.'•_' mm. deeper than Fig.

IS X ;i.") times; C, fifth cervical nerve ; fv, cardinal vein ; .i, subclavian
vein; ih; ductus Cuvieri ; I, lung; pli, phrenic nerve.

as well as in section. The se]itum transversum is not as per-
pendicular as in either younger or older stages (LXXVI and
II), but in general this embryo is intermediate between them.
A separation between the jiericardial and ]ileural ca^lom now
Viegins to make its appearance by means of a constriction in
its walls, the ductus Cuvieri encircling the cwlom at this
point. The hing buds hang free into the pleural ccelom,

Apkil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL 15ULLETIN.

1G5

iiiul the liver and stomacli into the peritoneal eo'lmii. Tli.^
dnctus t'livieri lieb in a riilue of tissue eneirclini;- tiie lanal di
coniniunieatitin lictween the pericardial and pleiiial iddniii.
In this eniliryo the ridge has no mesentery, as descrilied by
His {V\g. 18), hut in sagittal sections of the same stage
(CXXXVI) tlie mesentery is yiresent. As yet there is no

KiG. 20, — Section tlirousili embryo LXXX, .2(i mm. deeper tli;iii Fiij.
li) X 2.5 times; <',.,. si.xlli cervieiil myotome; <i, aorta; iv, eardiual vein;
.«, stomach; ", iiinljilical vciii ; //«•, lower peritoneal cavity.

indication of a line of se|iai'ation between the plciiial and
peritoneal cceloni in LXXX. Imt in ('XXX\'l ihei-e is an
elevation on the d(ii>;d wall (d' llie |il('iiial cii'lniii, l''ig. 21,
wliieh encircles the long ami joins the dnrsal end of the
s('|itnni li'ansversniii, 'i'his is one of the ]iillars of Uskow

FiG. :ll. — Sa'jiltal section tliroii2;li an embryo, ."> mm. lonii;. No.
CXXXVI X 2'} times; /i, lieart; i-i\ cardinal vein; xl, septum trans-
versuni ; ', hoii;-; .s, stomacli; k, arm; jir, pulmonary rid:;'e.

(ir the beginning <>( a ridge which I shall term the juiliiioiiiiri/
ridi/e.

Fig. 20, coni]iared with Kig. 1o. shows that tlu> foramen ol"
Winslow has moved more lapidlv Inwards liie tail than the
Iieart. A section through it strikes the heart sqnarely in
one case, while in the nther it does not tmieh the heart hwi
strikes the li\cr mily. This is in [lai't i\\tt' ti> the direction
of the sectiiiii in thi' Iwd specimens, and in |iiii'l to the shift-
ing of till.' fdrameii uf Winslow with (lie recession of the

stomach. The cervical nerves are sefiarated in No. LXXX
with the exception of an anastomosis lielween the fourth and
the liltli. j-riim this piiint the pliri-nic nerve arises. Fig. 19,
and passes to the lateral side of the parietal ccelom and lung.
In a later stage it reaches the se])tum transversum through
the plenro-]iericardial menilirane of I'skow.

I have now followed the transformation of the relatively
sim]ile C(el(iiii of the head and neck from the time it is well
I'diiiied ill an embryo of the end id' the second week to the end
of the tiiird week. During this time tiie pericardial cadom
has moved away from the head and the pericardial cavity
is well lUitlined. but the membranes which divide the ccelom
intii pcriearilial. pleiiial and jieritnncal spaces have not yet

FiQ. 'J2. — Rccoustnictiou of embryo No. II x 30 times; 7>, bronclins;
X, liver; P/i, plirenic; 1, ,?, ,?, 4 branchial pouches.

appeared. During the foui'th week both of these membranes
a]ipcar, but llicy are not well delined iiiilil the fifth week.

Fig. 22 is from a profile rcconslniclinn of I'hnbryo 1 1, show-
ing the relation of the organs to tme another. A cast of the
colon of this embryo is given in Fig. 23. The extreme ventral
kinking of the heart is shown in this stage and from now on
it begins to sink more and more into the body as the liver
recedes, 'i'lie cinnmunieation lictwecii I lie pericardial cielniti
and the |ilciiral eoelom is reduced to a narrow slit lietween the
Cephalic end of tlie lung bud and I lie iliictus Cuvieri. It
a)i]iears as if a simple adhesion of the walls of the slit would.
com|ilctr the closure of the pericardial space. Fig. 24 is a
.section Ihroiigh this space, striking the seventh cervical myo-

16G

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-123-123,

tome and the tip of the phrenic nerve. It shows that the
nttachnient of the ductus Cnvieri is no longer hroad, as in
rnibrvd IjXXX, Ijiit is narrow, formino- a mesentery as de-

fiG. 23. — Cast of coelom of embryo II x 20 times; /', perieiirclhil
coelom ; L, coelom encircling to liver.

scribed by His. On the dorsal side of the ductus there is a
ridge wliicli liegins as tlie ductus projects into the coelora and
gradually I'luis over into tlie lobe of the liver. Tliis ridge
is very pi-ononiiced and is also well shown in llu> sections of

-:^^4-''U

Fig. 24. — Section tlirousb the seventh cervical segment of the embryo
7 ram. long. No. II x 2.5 times; ('., seventh cervical myotome; rv, card-
inal vein ; ili; ductusCiivieri ; ?<)•, brachial iilexus; /(/•, pnlmi>?i;ny ridge;
///(, jihrenic nerve; h, bronchus; h, heart; hn, bulbns aorta'.

His's emljryos. A and 1>, as given in his Alhix. The relation
of this ridge to tlie phrenic nerve as well as its form in older
endiryos makes of it the Anlfuje of both the pleuro-])ericardial
and pleuro-pcritoneal membranes. It lies in the sagittal plane

of the coelom and as it passes the region of the fourth and
fifth cervical noi-ves receives into its substance the phrenic
nerve which ]iasses on tlie caudal side of the ductus Oiivieri.
Soon the lung bud grows against this ridge, causes it to bulge.
and with the rotation of the liver towards the head the ridge

Fig. 35. — Section through the embryo 7 ram. long, .6 ram. deeper than
Fig. 24 X 2.5 tiraes ; T,, first thoracic myotome ; ci\ cardinal vein: Tl'fi,
Wolffian body; .<:, stomach; Ipc, lesser peritoneal cavity; ?, liver; //,
heart; kI, septum transversum.

is divided into two parts; (1) the cephalic end which retains
the phrenic nerve and ductus Cnvieri and forms the pleuro-
pericardial membrane, and (2) the caudal end which remains
attached to the tip of the dorsal end of the septum trans-

Ph :'^

-y7'

fr'

, ^ Li.

Fig. 26. — Sagittal section through the embryo (>..5 mm. long. No.
CXVI X 25 limes; /jA, ]>haryn\; /j/-', first branchial arch; 6'(, bulbns
aorta'; (f, auricle; /'. ventricle; ^ Inng ; //, liver; />i\ pulmonary ridge.

\ersum and the liver mi the one hand, tlie body-wall on the
other, til f<iriii the ]ilcui(i-|ieritoneal membrane.

Figs. 26-28 show tliis ridge in sagittal sections in Embryo
rXVI. a specimen not (piite as large as No. II, but somewJiiit

Ai'eil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

IG'i

more advanced in developnu'iit. In P^ig. 26 its cephalic end
a])])ears as a broad menibiaiie which in a section nearer the
middle line extends to the liver on the ventral side and'

^ L'.v

\^^:v>^:v.^>^^

vs-^^v

y^PR

Fig. 27.— Section tliiougli tlic embivo 6..5 mm. louir, .1 mm. deeper
than Fig. 26 x 2.5 times, /i/i, pbarvux ; <(, arm; pi; ijulmonary ridge ; I,
luug.

it begins to widen at its dorsal end hand in hand with tlu
rotation of the liver. Fp to this time the se]itnm trans-
versnm is pai-allel witli the vertebral eohimn. with the heart

i^i^

wb'pr" "~"'

Fig. 28. — Section tlirough tlae embryo 6..5 mm. long, .13 mm. deeper
tliau Fig. 27 x 2.5 times; <«■, oesophagus; n, aorta; I, lung; li, liver;
11'/), Wnltliuu body ; jir, pulmonary ridge.

Fig. 29. —Lateral view of the iniliiionary membrane and surrounding parts of the embryo 7 nun. long. No. II x 30 times; «,
auricle; '', ventricle; /, lung; /(, liver; II A, Wolllian body; ///•, pulmonary ridge; ''., eighth cervical myotome.

aecoiMpaiiics the ductus Cnvieri to the body-wall mi tlic
dorsal side, I""ig. 21, pr. Stil more towards the midlino the
ridge ends as a decided elevation iiuiiicdiately to the eainhd
side of the ti]) of the lung.

After the lailnionary ridge is well formed (as in I'hnbryo IT)

on its venti-al siiU' ami tlie liver on its dorsal side projecting
into the ]ici-itoiieal eodom, as shown in No. H. This eondi-
tion was hruught about at the time of the bending of tln'
head when the viscera were forced towards the tail and into
this position. The cejihalie end of the pericardial crelom

168

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

is tluis Lent over the septum transversum but the nuiin part
of the head (•<vloiii remained parallel with the si)iiial eoliiiiin
on either .side ol' llie liody. This process may he termed tlu:
rolling over of the heart.

In the next stage the heart rolls in a dorsal diret-lioii and
the liver in a ventral direi-lion. 'i'his process has already
hegnii in endiiyo CLXIII and C^XllI. In so doing the lung
buds become Ijuried deeper in the body of the embryo and
the liver gradually changes its |iosilion from the dorsal side

Fig. 30. —Lateral view of the pulinoniiry membraue and siinomuliii!;-
parts of tlie embryo '.I mm. lont;; No. CL.XIII x 13i.< times, (\, eiiihtli
cei-vical myotome; //.liver; I, liiuir; ■■-■, stomach; 1I'6, Wolfliaii botly ;
y>/(, plirenic nerve; y«', pleuro-perieardial membrane ; ^/yj. pleuro-peri-
tonuMl mcnihraue.

of the septum transversum to its ventral side. The septum
transversum undergoes almost a half-revolution. The cudom
containing the liver lobe evaginate.s and becomes incorporated
with the general ahdiuniual ca\ity.

I'"iii. 31. — Section through the filth cervical myotome of the embryo
'.I mm. Icing, No. CLXIII x l-}^ times; (',,, llfth myotome; (•<■, cardinal
vein; tir, ductus cuvieri ; br, brachial ple.xus; jih, phrenic nerve; /ir,
cephalic end of the pulmonary ridge forming the beginning of the
pleuro-pericardial membrane.

\\'itli (lie rolling of the heart the cielom connecting the
pericardial with the pleural space is kinked at the points of
juncture between these cavities. At this point the duct of
( 'uvier enters the heart. Soon fi-om its dorsal boi'iler the
]nihnonary ridge arises which is semicircular in form and
reaches from the liver to the dorsal walls of the credom as
ilescribed under I'hid.iyo II. It is shown in section in Fig.
'H, and in a lateral reconstruction in Fig. 20. The pulmon-

ary ridge is really an extension of the septum transversum
from the lobes of the liver to the tij) of the AVolffian body.
,Vs the heai-t nio\'es in the dorsal direction and the liver in
the ventral dii'ection it is the dorsal end of the septum trans-

'^•^'HCoc/— -^ ^^e^, — ' — Ph

PCoe

Fig. 33. — Section through the embryo '.I nun. louir, -Wi mm. deeper
than Fig. 31 x 12,'.; times; ('„, si.xth cervical myotome; •■/•, cardinal
vein; p/i, phrenic nerve; jjc, pleuro-pericardial membrane; ////, plcuro-
peritoneal membrane; pl-cve, pleural coeloni ; /j-mc, peritoneal coelom.

versum which moves most ra])idly in the cbrection of the tail.
In so doing the pulmonary ridge grows rapidly and divides
at its dorsal end into two memtiranes, one containing the

Fig. 33 Section through the embryo '.I mm. long, .10 mm. deeper

than Fig. 33 x 13)^ times; C^, eighth cervical nerve; pp, pleuro-peri-
toueal mcmbi-anc.

Fig. 34.— Section through the embryo !) mm. long, .84 mm, deeper
than Fig. 33 x 13).^ times; y,,, third thoracic myotome; //«■, lower
peritoneal cavity ; 117), Wolfliau body.

duct of Chivier ;ind phrenic nerve, and the other still encirc-
ling the lung bud. In this division we have the beginnings of
the jdeuro-pericardial memhrane of ITskow, and tlie pleuro-
peritoneal mendjrane of Brachet.

Apiul-May-June, 1901. J

JOHNS HOPKINS HOSPITAL BULLETIN.

IGi)

'Pill' iiiiliiiiiiiary ridpo is well formed in Embryo II. It
appears as a ridge of tissue passing towards the head from
the lobe of the liver on tlie dorsal side of the ductus Cnvieri
and then aloui;- th.e dorsal walls ol' the rcrhim to the meso-

^f."-'-

^LPC

Fig. 3.5. — Sagittal section tlirnuijli the unibrvo s nini. loiii:. No. C'XIII x
10 times; J, lower jaw ; .s-^z-uc, siuus lu-aecervicalis ; ;, fouitli cervical
nerve, /)/(, phrenic nerve; st, septum transversuin; ih\ iluctus Cuvieri ;
/)<•, pleuro-pericarilial membrane; pp, pleuro-peritoiieal membrane; /,
lunif; ,v, stomach; 'yjr, lower peritoneal cavity ; T'/i, Wolffian body.

(■ai-(liuiii. \\liere it ends in the pillars of Uskow. As the
einhryi) gidws larger tlie ductus t'uvieri separates more and
mnic friiiu the latei'al liody-^all. and in a incasurt' sliifts intn
the [lulmonary ridge, whieh at its nidst emne.x point grows in
the form of a ridge towards the heart. This secondary ridge,
which is present in C'LXIII. linally se|)arates the ]ilenral
from the pericardial cavities and comiiletes the jilcnro-peri-
cardial membrane.

Ki<i. :i(I. — Section through the embryo S mm. lony nearer the mitldlc
line tliau Fiif. 3.5 x 10 times; ;/'■, ductus Cuvieri; I, lung; .«, stomach;
Pli, pleuro-peritoncal membrane.

Tile piilniiiuary ridges from thcii' beginning to tlieir separa-
tion into the pleuro-pericardial and pK'urn-pri'itcnu'al niem-
liranes a]ii)ear as two ears to the se[)tum transversiun, c-\tend-
ing along the ducts of Cuvier in tlie sagittal plane id' the
body and at right angles to the phiiie of tlie septum trnns-
versnm. Judging by tlie relatimi n\ the phrenic iier\c to the
])ulmonary i-idge tlie poi'tion (d' it I'n tlie dorsal siih' (if the
ductus Cu\ieri Clint, Lining the phrenic nerve, the pnrtimi con-
taining the ductus Cuvieri. and the sccimdaiy ridge nf the

ventral side of tlie ductus Cuvieri, form the pleuro-pericardial
membrane, 'i'he portion of the pulmonary ridge on the
caiuhil side nf tlie ]ihrenic nerve gives rise to the pleiirn-
peritiiiie;d mend ii a lie. In so doing it gradually shifts over

■Sl;

Fig. S7.— Sagittal section through the embryo 10 mm. long. No.
CXIV X 10 times; /(/j, pleuro-peritoneal membrane.

the lung hulls and iinally t'omplctely separates the jileuial
rriiui the peritoneal cavities.

The growth of the plenro-pericai'ilial meiiihr;ine towards

Fig. 3S. -Lateral view of the embryo 11 mm. long, showing the
pleuro-pericardial and pleuro-peritoneal membranes. No. CIX x S.'.j
times; /-, lirst rib; /, lung; 11, liver; p/i, phrenic nerve in the pleuro-
pericardial memljrane; .s, stomach; ir6, Wollliau body; (ip. pleuro-peri-
toncal membrane which is not quite completed.

the head ami the ]ilenro-peritoneal towards the tail widens
the dorsal projection of the septum transversuin and iiiin
this wide hasi' the lung Ijurrows throwing the jileuro-ii.'ri-
card-ial membrane with the phrenic nerve to its medial side.
The fate of the pulmonary ridge is shown in Fig. 3(1. which
is from lOmbryo CL.XIII. Sections of this embryo are shown
in l-'igs. 31 to 31. They show again that the pulmonary
ridge reaches rroiii the diietus Cuvieri to the ti|i of the lung,
and the phieiiie nerve. It is readily seen from Figs. 30 and

170

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. iai-122-123.

o2 liow the ])lirenic nerve is pushed to its permanent position
liy the further rotation and recession of tlie septum (rans-
versum and livei'. ajid the lateral growth of the lungs to
encircle the heart.

PC .

"it \

iMmMiK

Fig. 30. — Section through the body of the embryo 11 mm. long. No.
CIX X 10 times; /i/i, plirenic nerve; yjc, pleuro-pericardial membrane;
.s7, septum transversum ; //. humerus; .;, tirst rib; .', second rib; /,
third rib.

Figs. ;J.j and 3lj are from sagittal sections of iMnlu-yo (.'XIII,
which is of the same stage as CLXIII. The iihrenic nerve is
shown throughout its whole course from the fifth cervical
nerve to the pleuro-])ericardial memhrane. The nerve re-
ceives a second hi'anch a few sections deeper frmn the sixth
cervical which unites with the main trunk hefore it enters

0 0 0 .f W-^

?h/

\y:^

" ^ -S[

Fio, 40. — Section through the embryo 11 mm. Ion;;; .IS mm. deeper
than Fig. .39 x 10 times; /;/<, phrenic nerve; st, septum transversum;
P'-, pleuro-pericardial membrane; pjj, pleuro-periloneal membrane; J,
,.-', ,)', 4, ribs.

the pleuro-pericardial nienil)rane. Hanging from the pleuro-
pericardial memhrane is a section of the pleuro-|ieritoneal,
which in Fig. 36 unites with the dorsal wall of the cndom at
the head end of the Wolffian body.

About this time the portion of the ])ulinonary ridge des-

tined to heconii' the plcuro-]ieiicardial membrane unites with
the root of the lung hud and com]iletely closes the pericardial
cavity, Fig. 37. By this union the course of the duel us
Cnvieri is from the body-wall to the heart throtigh the pleuro-
pericardial mendirane, and the plane of the pleuro-pericardial

Fig. 41 Section through the embryo 11 mm. long, .46 mm. deeper

than Fig. 40 x 10 times. The pleuro-peritoueal membrane is incom-
plete on one side, .;, j, .7, i:, ribs.

membrane is jiractically that of the septum transversum, the
two together being transverse to the body of the embryo.
The phrenic nerve at this time is in the plane of the septum
transversum and reaches its dorsal tip through its projection,
the pleuro-pericardial membrane.

Immediately aftei the completion of the pleuro-pericardial

v3^^^

V^-^'

Fig. 42. — Sagittal section through the embryo 14 mm. long. No.
CXI.IV X 10 times, ///>, phrenic nerve; /'/, tenth rib; .s, stomach ; /,-,
kidney; 11', Wolllian body.

membrane the rotiition id' the liver and septum transversum
is accelerated, and by the time the embryo has grown to be
11 mm. long (CI.X). tlie liver is practically in its adult posi-
tion. The rapiil rotation of the liver, especially at its dorsal
end, has elumged the relation of the planes between the

April-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

171

pleuro-pericardial membrane to tlie septum transversiim from
parallel to right angles. Now the septum transversum is in ^
the plane of the plenro-peritoneal membrane (Fig. 38). With'
the recession of the septnm transversum, especially at its

\^ -'

PP-: <PP

■J
3

Fio. 43. — Section tlirough tbe opening between tlie pleur-il and
peritoneal cavities in the embryo 14 mm. long x .'50 times; .s, stomach;
I, hing; /<p, pleuroperitoneal membrane; nr?, adrenal.

dorsal end, the evagination of the co?lom containing the
liver and stomach is complete, throwing them into the general
peritoneal cavity.

Figs. 39, 40 and 41 are sections through the plenro-peri-

■ mi

M \

Fio. 44 Sagittal section through the body of the embryo 10 mm.

long. No. XLIII X 10 times; .9, ninth rib.

cardial and plenro-peritoneal membranes of Embryo CIX,
Fig. 38. They give the relation of the pleuro-pericardial and
plenro-peritoneal membranes to the surrounding structures.
The heart is now in its permanent location in the thorax and

the liver is in the abdominal cavity. The septum transversum
with its extension, the pleuro-peritoneal membrane, stretches
across the body from the tips of the embryonic ribs. But in
the thorax lie the lungs, and their further growth into the
lateral walls of the embryo and septum transversum will
make them encircle the heari:, thereby enlarging the pleuro-
pericardial membranes and changing j)osition of the phrenic
nerves.

After the heart, lungs, liver and stomach are located in
their permanent positions the plenro-peritoneal membrane
grows rapidly and soon closes the opening between the pleural
and peritoneal cavities. Fig. 42 is from a section lateral to
the opening showing the phrenic nerve throughout its great-
est extent. In this specimen the marked growth is in the
pleural cavity. Fig. 43 is from a section through the opening
on a larger scale, including also the adrenal. A stage
slightly more advanced is shown in Fig. 44. In this speci-
men, as in the one above, both pleural cavities communicate
with the peritoneal. In Embryo LXXIV, Fig. 4."i, the iileum-

FiG. 4.5. — Transverse section through the embryo 14 mm. long. No.
LXXIV X 10 times; 7, seventh rib. The plenro-peritoneal membrane ;
pp, is incomplete on one side.

peritoneal nienibrane is complete on the right side and in-
complete on the left side. The reconstruction of this embryo
shows that the opening is very large and extends from the
seventh rib towards the tail. It may be an instance of re-
tarded development, because in embryos 19 mm. long the
membranes are as a rule complete on both sides of the body.
To what extent the permanent diaphragm is formed from
the pleuro-peritoneal membrane it is difficult to determine.
Undoubtedly the portion of the diaphragm on the caudal
and dorsal sides of the pleuro-pericardial membrane is formed
from the pleuro-peritoneal membrane. That portion of (lie
diaphragm on the cephalic side is formed from the septum
transversum. Itut the diaphragm is greatly extended on the
lateral sides of the heart after the embr}'o is 20 mm. long by
the extension of the pleural cavities around it. It appears
from the models that this portion of the diaphragm is also
formed directly from the periphery of the septum trans-
versum.

172

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

OBSERVATIONS ON THE PECTORALIS MAJOR MUSCLE IN MAN.

By Warren Harmon Lewis, M. D.,
Assistant in Anatomy, Johns Hopliiis University.

The Adult Muscle.

The peculiar twist in the sternocostal portion of the pector-
alis major muscle is described in the various text-books on
human anatomy. In general, the descriptions would indicate
that the posterior layer of the tendon of insertion is formed
in such a manner that its highest fibres have the lowest origin
on the thorax, and the lower the fibres at the insertion the
higher their origin on the thorax. There must thus be a
crossing of fibres. This crossing is generally represented as

direction of the fibres which form the apparent twisting. For
this purpose specimens were taken from the dissecting room,
from 1)odies embalmed with the carbolic acid mixture.' The
muscles were placed in equal parts of glycerine, water and
nitric acid for 24 to -18 hours. In most of the specimens
thus treated the direction of the fibres was easily obtained
as the connective-tissue elements were partially disintegrated
and easily torn.

.— Gq

— h

Fio. 1. — Diagram of an adult peetoralis major muscle, c p, clavicular portion; s <• p, sternocostal portion; 1, 2, 3, 4,
5, 6, are overlapping bundles of fibres of the same ; 6 u, portion of the posterior layer of the tendon of insertion comirg from
fi; /i, humeral end of the muscle.

taking place at or near the concave portion of the lower or
axillary border of the muscle. I have found many anatomies
incorrect or very incomplete in their description of the forma-
tion of the posterior layer of the tendon of insertion as well a.s
the direction taken by the remaining sternocostal fibres, which
go to the anterior layer of the tendon. These descriptions
correspond fairly well with the direction the fibres appear to
take when one examines the muscle superficially.

I have examined carefully twelve muscles to ascertain the

My dissections have shown in every case, (1) that the
lowest fibres of origin go to the lowest end of the posterior
layer of the tendon of insertion (Figs. 1 and 2), (2) that there
is no crossing of fibres forming this posterior layer, and (3)
that a peculiar fan-like arrangeuuMit of the bundles of fibres
in the whole sternocostal portion is present (Figs. 1 and 2).

After the maceration, I found the muscle had a tendency

IF. P. Mall, The Preservation of Anatomical Material for Dissection,
Anat. Anz., Bd. xi, p- TBO, 1836.

Apeil-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

173

to split into several overlapping bundles (Figs. 1 and 2; 1, 2,
3, 4, 5, 6). The number aijd size varies in different muscles.
It will be seen from the diagram (Figs. 1 and 2) that the over-
lapping is more and more marked toward the humeral inser-
tion.

The clavicular portion and upper five bundles form the
anterior layer, and the sixth bundle the posterior layer, of
the tendon of insertion. The lower fibres in each bundle,
wliich are the superficial overlapping ones, reach to the lower
end of the tendon, while the upper, deeper ones are more
and more overlapped and pass to the u]iper edge or near to
the upper edge of the tendon. Each bundle, as it approaches
the tendon of insertion, spreads out and becomes thinner.

Development.

I have attempted to trace the development of the muscle
in a series of human embryos and to explain the origin of
the peculiar arrangement of its fibres. For this purpose I
have studied the muscle carefully in embryos varying in
length from 9 to 40 mm. The first indication of the muscle
I have been able to note was in an embryo of 9 mm. in length.
In an embryo of 40 mm. the adult form is present. Recon-
structions of the younger and dissections of the older embryos
were made to study them.

In a human embryo measuring 9 mm. in length (No.
CLXIII),^ the pectoralis major and minor muscles are repre-

FiG. 2. — Diagram of cross-sections ot tlie muscle talcen at //;, ;
1. ,1, auterior laj'er of tendon ; P, posterior layer.

Tlie distance to which the muscle fibres go outward toward
tlie humerus decreases from above downward and thus aids
in keeping the distal end of the muscle thin.

The posterior layer of the tendon is continuous with bundle
6 (Figs. 1 and 2). It gradually spreads out and becomes
thinner on approaching the luimerus. As in the other bun-
dles, its lower fibres reach the lower and its upper fibres the
upper border of the tendon. The size of this bundle varies
greatly, especially in the amount of overlapping toward the
origin. Most of its fibres constitute the abdominal portion
into which the muscle is sometimes divided. The accessory
bundles of muscle having, as a rule, costal origin and which
lie beneath the main muscle, arc inserted into this posterior
layer.

i; op; and rij, in (Fig. 1). Numljers and letters remain as Fig.

sented by a mass of closely packed cells without sharp limits.
As there are no muscle fibres in this tissue I shall call it pre-
muscle tissue. The other muscles of the arm and shoulder
girdle are also represented more or less clearly by this pre-
muscle tissue. There are, however, muscle fibres in the
muscle-plate system. Here the muscle plates have fused
into a continuous column and in the costal region extend
along the intercostal spaces, partially surrounding the ribs
and fuse together beyond their tips into a ventral plate.
This muscle-plate system contains fibres, is farther advanced

'The numbers here given correspond with those in the catalogue of
the collection of human embryos in the Anatomical Laboratory of the
Johus Hopkins University.

174

Johns hopkins hospital bulletin.

[Nos. 121-122-123.

and has a different appearance from the premuscle tissue,
which is lateral to it and in the arm. In Fig. 3, which
is from a wax reconstruction of the right arm region of
this embryo, the costal portion of the mnscle-plate system
is seen (m.pl.s). Lateral to this is the lateral premuscle mass
{t.pin). At the level of the first rib (cI.) the pectoral pre-
muscle mass ip.pm) leaves the lateral to join the general arm
premuscle sheath (a.pm.) along the ventral side of the proxi-
mal half of the condensed tissue which represents the hum-
erus. The proximal end of the humerus lies opposite the
interval between the fifth and sixth intervertebral disks
(dVc, dVIc), the distal end opposite the first rib {cl.). The

tion into masses, such as the pectoral, latissimus dorsi and
levator scapulfe and serratus anterior. It is impossible for
me in the case of the pectoral mass to determine how far
caudally into the lateral premuscle tissiie it extends, or just
where to draw the line between it and the neck premuscle
mass. Its humeral end is lost in the general arm premuscle
tissue. Its location and correspondence with the muscle in
the next stage and its nerve supply lead me to believe this
to be the pectoral mass.

The pectoral premuscle mass is supplied by three nerves,
from the brachial jdexus, the fibres of which come from the
1'/, VII and VIII cervical and I thoracic nerves. It will

apm

Fig. .5.— Ventral view of a wax reconstruction of tbe arm region of a liumaii embryo measuring 9 mm. in lengtli (No. CLXIII).
Enlarged TM times. AB, median liiie; c I, c II, <■ HI, -■ IV, ribs one, two, three and iour; d IV <■, (/ V c, d VI c, d VII c, fourtli,
fifth, sixth and seventh cervical intervertebral dislis; a. iiiu, premuscle mass eusheathing the arm; I. pin, lateral premuscle mass;
;j. pin, pectoral premuscle mass; s. /)»i, scapular premuscle mass.

scapula lies imbedded in the scapular premuscle tissue
(s. pm). The clavicle is not present at this stage. The
intervertebral disks are of condensed or closely packed cellu-
lar tissue {dIVc, etc., to dIVt). The ribs are of condensed
tissue and project ventrad from the adjoining parts of the
intervertebral disks and vertebral bows.

It is very difficult to determine the exact limits of the pre-
muscle tissue; in a few places it is very sharply marked off
from the surrounding mesenchyma as at the ventral end of
the neck premuscle mass. The entire arm between the
central skeletal core and the integument is filled with this
tissue. At the root of the arm there are signs of a separa-

be seen at this stage that the pectoral mass is mostly cervical
and lies in the region of its nerve supply.

The fibres of the brachial plexus are directed laterally and
have scarcely any caudal inclination.

In an embryo measuring 11 mm. in length (No. CTX),'
there is great advance in the musculature of the arm. Many
of the arm muscles, especially the proximal ones, can be

3 Mall, (F.). The value of Embryological Specimens, Maryland Med.
Journal, October 20, 18!)S. A Contribution to the Study of the
Pathology of Early Human Embryos. Contributions to the Science of
Medicine, dedicated to William H. Welch, Johns Hopkins Hpsi)it«l
Reports, vol. ix, I'.IOO.

Apeil-May-Juxe, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

175

recogiiizi'd. Insti'ad uf premusole tissue we liiive distinct
fibrillation.

The pectoral nuiscle mass extends from the rejiion lateral
to the ends of the first three ribs cephalolateracl to the
cephalic border of the humerus. Its cephalic portion is
closely associated with the medial end of the clavicle (Figs.
4 and 5, cp.). There is no definite attachment of the
mnscle to the ribs. The pectoralis major and minor are
closely united. The latter is indicated by a bulging toward
the coracoid process {p.min., Figs.. 4 and h). I have with
difficulty traced the general course of the fibres in the major
portion of the mass, as will be seen in Fig. -5. The fibres
from the clavicle do not appear to overlap the sternocostal
fibres but occupy the proximal part of the insertion, whih'
the sternocostal fibres occupy the distal. See Fig. 6, which is
a diagram of the relation of these fibres close to their inser-
tion into the humerus.

It is also worthy -of note tiiat the pectoralis muscle has
extended caudally to the level of the tip of the third rib.

In an embryo measuring 16 mm. in length (Xo. XLIII)/
the two pectoral muscles are eutii-ely sejiarate. The pector-
alis major muscle assumes much more the adult form than in
the previous stage. The entire arm has migrated caudally
and with it the pectoralis major mnscle. It now extends to
the sixth rib (Fig. 7, cVI.). The clavicle has extended
to the tip of the first rib, where it joins the cephalic end
of the sternal anlage (si.. Fig. 7). The clavicular portion of
the muscles is carried with the clavicle toward the median
line. The humeral end of its filjres are seen to overlap the
sternocostal fibres near the himrerus (Figs. 7 and 8). There
is a distinct gap between the clavicular portion (Fig. 7. cp.)
and the sternocostal portion (Fig. 7, scp.) near their origins,
The fibres of the sternocostal portion present a slight ten-
dency to separate into bundles in which their is an overlap-

lacar

N.Y.C

d.VIC

d.YHC-

Fig. i. — .Mediau view of a wax reconstnictiou of tlie arm i-«;;iou of a human embryo measui-iiig- 11 mm. iu leni^th (No. CIX).
Eularged 30 times. .1, acromiou; c II, second rib; c, coracoid process; riii\ carpus; ': p, clavicular portion of the pectoralis
major; cZ, clavicle; i;h, chorda dorsalis split in the median line; d VI c, d VII t, sixth and seventh cervical intervertebral dislcs ;
d I (, first thoracic intervertebral dislc, from which the first rib is seen arising; inrnr, metacarpus; p. m, pectoralis major
muscle; p.miu, pectoralis minor bulging toward the i'or.acoid process; n,\ c, fifth cervical nerve going to join the brachial
plexus; bp, brachial plexus ; c, radius; id, ulna; .•;, scapula.

Figures 4 and .) are from a wax reconstruction of the right
arm region of this embryo. All muscles but the pectorals
are omitted.

The ])ectoral muscle mass is supplied by four branches of
the i)raehial plexus, two from the outer and two from the
inner cord, the fibres of which can be traced to the Vf. VI f
andVIII cervical and / thoracic nerves.

It is of special note at this stage, that the larger portion
of the muscle lies above the first rib, reaching about to the
level of the fifth cervical intervertebral disk; that there is no
overlajiping of its fibres; and that the clavicle only reaches
about one-half the distance from the acromion to the first rili.

ping of the deep portion of the lower by the superficial por-
tion of the u]iper ones. This is more marked toward the
insertion, as will be seen in Fig. 8, where the overlapping is
quite complete. I liave not been able to make out at this
stage anything which corresponds to the deep or posterior
tendon and, as will lie seen later, it probably does not exist
at this stage.

' .Mall, (F). Development of the Human Coelom, Jour, of Murpli., vol.
xii, No. 2. Development of the Internal Mammary and Deep Epigastric
Arteries in Man, Johns Hopkins Hospital Bulletin, Nos. 90-111, 1898.
Development of the Ventral Abdominal Walls iu Man, Jour, of Morph.,
vol. xiv. No. -i, 1S08.

170

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-132-123.

The nerve supply is as in the adult.

Embryo No. XXII,° measuring 20 mm. in length, shows
aboiTt the same condition as in Embryo No. XLIII. The
separation of the sternocostal portion into various bundles
is especially well marked. They have no relation to the ribs
so far as the number and position is concerned.

Fig. 5. —Ventral Tiew of a portiou of the model sliowu iu Fig. 4,
showing the pectoral muscle mass and its relations to the scapula,
clavicle and humerus. A, acromion; c, coracoid process; cl, clavicle;
/(, humerus ; p. m, pectoral miiscle mass ; c p, clavicular portiou \ » e p,
sternocostal portion; p. min, pectoralis minor bulging; s, scapula.

In an embryo 32 nun. in length (No. C'XXIX)," we find
that the j^osterior layer of the tendon of insertion has made
its appearance (Fig. 9). The fibres which go to this tendon
come from the most caudal portion of the rnuscle. This
posterior layer is about one-fourth the width of the anterior
layer of the tendon of insertion. The embryo was studied
with a dissecting microscope and so far I could determine

-C,p

scp.

Fig 6. — Diagram of a cross-section of
the pectoralis major fibres near their hum-
eral insertion. Enlarged 50 times. P,
proximal end of the same; c p, clavicular
fibres; s c p, sternocostal fibres.

the arrangement of its fibres was otherwise similar to the
adult.

In an embryo 36 mm. in length (No. XC). we find the
posterior layer of the tendon of insertion nearly three-fourths
the length of the anterior (Fig. 10). Otherwise the muscle
appears to be much as in the adult. The pectoral region
was studied with a dissecting microscope.

s Mall, Maryland Medical Jour., October 3'.l, 1S!I,S. Ibid., .Tour. Morph.,
vol. xiv. No. 3, ISOS. Ibid., Johns Hopkins Hospital Reports, vol. ix, 1900.

"Mall, Contributions to the Science of Medicine, dedieated to
William H. Welch, Baltimore, liiOO, Johns Hopkins Hospital Reports,
vol. ix, 1900.

In an embryo of 40 mm. in length the posterior layer of
the tendon exceeds the anterior in width, and the muscle
presents the adult form.

Fig. 7. — Ventral view of the pectoralis major muscle in an embryo
measuring 16 mm. iu length (No. XLIII), taken from a wax recon-
struction of the arm region of the same. Enlarged 30 times, hi c p,
sternocostal portion, various artificial divisions of which a, h, c, cl, are
shown near their insertion in Fig. s ; ,■ I, c II, <• V, c VI, euds of first,
second, fifth and sixth ribs, which, with the third and fourth join
together to form the left half of the pectoralis major muscle; A, hum-
erus, p. m, pectoral muscle mass; scp, sternocostal portion ; s, body
of the scapula; M, sternum; c p, clavicular portion; <■;, clavicle"; !i,
humerus.

Summary.

It is thus seen that the pectoralis major muscle arises in
common with the minor from a premuscle tissue which is

Fig. .s. — Diagram of cross-section of the
pectoralis major muscle seen in Fig. 7,
near its insertion into the humerus. En-
larged .30 times. P, proximal; ant, ventral
surface ; c p, clavicular portion ; a, b, c,
approximate position of the corresponding
muscle bundles of Fig. 7.

located for the most ]uirt aliove the fir.^t ri1:i. It gradually
migrates or sliifts to the costal region, as has already been
noted by Dr. Mall.' During the course of this migration it
splits into bundles. The clavicnlar portion i.s the fii'st to
split off. Later the sternocostal portion splits into the major

■ Mall, Development of the Ventral .Abdominal Walls iu Man. Jour,
of Morph., vol. xiv, No. 3, IMIIS.

April-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

17-

and minor. The major becomes arranged into a series of
overlapping bundles. As we have seen, the clavicular por-
tion is the upper and most superficial. During the migration
the overlapping of the sternocostal Inuidlus is such that
superficial fibres of each l.iundle have descended farther than
the deeper, owing perhaps to the greater friction of tiie

-a

Fig. 9. — Diagram of tlie insertion of
the peetoralis major muscle in an embryo
30 mm. in lengtli (No. CXXIX). Enlarged
16 times. A, anterior layer of the tendon;
6, posterior layer.

latter against the chest wall or to their earlier attachment.
The lower bundle seems to be the last to be differentiated,
and its tendon, the posterior layer of the tendon of insertion,
appears to gradually spread out toward the proximal end of
the humerus after the superficial or anterior layer is well
formed.

The early entrance of the nerves into the muscle while
still in the cervical region explains the adult nerve supply.

Explanation of Varieties.
It would seem that in the conditions existing between an
embryo of 9 and 11 nun. in length might be found a partial
explanation of such varieties as absence of the sternocostal
or clavicular portions and of the peetoralis minor with the
sternocostal portion. We have here a condition in which

-a

Fig. 10 Diagram of the tendon near

its insertion of the peetoralis major
muscle of an embryo 36 mm. in length
(No. XC). Enlarged 16 times. A, anterior
layer; 6, posterior layer.

the clavicle is absent and no attachment to the ribs exists.
The subsequent attachment to one or the other might not
occur and that portion of the muscle found wanting in the
adult. With absence of the sternocostal portion would be
associated that of the peetoralis minor owing to their early
fusion. In the tendency to split into bundles, with the shift-
ing of the muscle and fibres, the muscular bands which are
often found as the costocoraeoidens, sternalis, chondroepi-
trochlearis, etc., may have their origin.

ON THE BLOOD-VESSELS OF THE HUMAN LYMPHATIC GLAND.

By AV. J. Calvert, M. D., U. S. A.,
Palhological Laboratory, Board of Health, Manila, P. I.

The lynipliatic glands removed at autopsy from pest
cadavers have enabled me, on account of the extreme con-
gestion incidental to the disease and the reduction in the
density of the nuclear elements of the gland, to follow in
detail the course of the smaller vessels; the pathological
changes referred to are not of sufficient degree to destroy the
landmarks of the organ or to change the general relation-
ship of the parts.

In an earlier communication I showed the course of the
blood-vessels in the lymph follicle in the dog, and the pres-
ent report is made because it demonstrates that the same
arrangement is present in the human lymphatic gland.

The glands were fixed in Zenker's fluid, hardened in alco-
hol, sectioned in celloidin, stained in hematoxylin and eosin
and mounted in balsam.

The illustrations show the origin and distril)ution of the
follicular artery, the arrangement of the capillaries in the
follicle and the origin of the veins. The course of the

arteria; and vena; lympho-glandulae and the vessels of the
cord have been illustrated.'

From the above illustrations and the many typical pictures
seen in the slides the following scheme for the blood supply
of the human lymphatic gland may be described: The
arteri* lympho-glandulffl enter the gland at the hilus, pass
through the hilus stroma to enter the trabecule. In the
trabeculae arterial twigs are distributed to all portions of
the gland. On reaching the portions of the gland near the
proximal ends of the follicles small arteries arise which run
in the lymphatic structure more or less parallel to the sur-
face of the gland. These arteries give rise to the follicular
artery (Figs. 1 and 2) and supply the adjacent portions of the
pulp cords.

The follicular artery runs a straight course in or near

> The Blood-vessels of the Lymphatic Gland. By W. J. Calvert
Anatomiscber Anzeiger, xiii. Band, Mr. 6, 1897, p. 176.

178

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

the centre of the ]yiii]ih cord of its particiihir follicle, to
ahont the junction of I lie jiroximal with the middle third of
the follicle. The ftillicular artery may give off branches to
.«u])])ly the adjacent jmrtions of the cords. Near the centre
of the follicle the artery breaks np into a number of small,
straight, long capillaries which diverge to the periphery of
the fdllicle. In some cases these capillaries branch, in
others they do not.

Just beneath the periphery of the follicle these capillaries
turn and branching form a rich plexus of capillaries wdiich
in turn unite to form small veins (Fig. 6). The ])Iexus of
capillaries in the follicle is continuous with a similar
plexus in the cords.

The veins formed in the follicle run toward the jjroximal
end of the follicle to join a rich plexus of veins.

The arteries supplying the cords are, as a rule, quite short.

run in or near the centre of the cords and rapidly end in a
rich capillary plexus near the surface of the cord. This
plexus soon unites to form snudl veins which also run in or
near the centre of the cords, but in a |iortion of the cord
other than where the artery is found. The veins of the
cord soon join veins from neighboring cords, through the
anastomosis of the cords, to form larger veins which leave
the cords to join the vensE lymjilio-glauduliP.

The veins from the follicles and adjacent jiortions of the
cords unite to form a rich venous plexus, which lies within
the lymphatic structure. This ])lexus may bo considered to
be the origin of the ven;B lymjiho-glandula', which, like the
arteries, run in the trabecula? to leave the gland at the hilus.

The lymph channels are free from blood-vessels.

This arrangement of blood-vessels is also found in the
lymph gland of the monkey.

NORMAL MENSTRUATION AND SOME OF THE FACTORS MODIFYING IT.

(PRELIMINARY NOTE.)

By Cleli.v Duel Moshee, A. LL, M. D.,

Gi/nwcolor/iral E.rlcrne in the Johns Uopl'ins Ilospital Difiiciisarij.

The conclusions stated in this note are liascd on two kinds
of data — clinical and experimental. The first consists of serial
menstrual records of more than 300 women, collectively ex-
tending over more than 3000 nienstnud periods. A large
number of these records were made by the writer, month by
month, when the women Avere under her personal observation
in the Stanford University Gymnasium, and then were con-
tinued by the women themselves during holidays and vaca-
tions away from the university. The records were supple-
mented by preliminary statements, careful intermenstrual
notes, and subsequent letters. The usual physical examina-
tion for admission to the gymnasium was made by the writer
in many cases; to this was added an intimate knowledge of
the conditions under which the women were living and work-
ing. Second. laTioralory experimental data on the i-es])ii-a-
lioii,' urine, tcm])erature, pulse and l)lood — blood |)ressure,
blood counts, hemoglobin estimations and so on. Experimen-
tal work on the effects of clothing was also included. This
work luis been done in the physiological laboratories of the
Stanford and the Johns Hopkins Universities, and in Dr.
Kelly's laboratory. The first work was done in May, 1893,
in California, has been continued as o|i|iortunity offered
and is still in progi'css.

Some of the more important conclusions, which are based
largely on the blood-jiressure experiments and clinical data
will be reported at this time.

• "Respiration in Women," Preliminary report as thesis for M. A. de-
gree, Stanford University, May, 1.S94. Also paper presented at Cali-
fornia Science Association, .Ian. 3, IS',16.

McthuiL — Daily records of the blood pressure were made on
14 persons— 0 woincn and .'J men. The \vomen were selected
as representing normal conditions of menstrual health. The
iiK'U were all healthy adults and 4 were athletic, ^n at-
tempt was made to continue the records long enough to cover
at least two periods of change in pressure; in some cases
the observafions extended over 49 days and some are still in
progress. The blood-pressure records were made with the
sphygmomanometer of Mosso. The tracings were taken
daily at the same hour and under uniform conditions, per-
fect rela.xation being secured and all varialile factors ex-
cluded as far as possible.

Conchisions. — That a rhythmical fall of bl(jod pressure,
at definite intervals, occurs in iKith men and women. The
daily records of the blood-pressure with the sphygmoma-
nometer of Mosso on men and women inider similar con-
ditions of life and occu|)ation give curves apparently indis-
tinguisliahle in chai'acter. The fall in pressure in women
occurs near or at the menstrual period. In all of the 14
series of records the fall of blood-pressure was gradual from
the mean average pressure. This from day to day shows
oscillations .within rather definite limits. The maximum
fall of ]iressure may extend over two or three days and the
coi-responding rise to the normal average jn'ossure is gradual.
There is usually a jireliminary rise, above the normal average
jiressure; this occurs from 3 to 5 days before the onset of the
main fall of pressure, wdiich constitutes the principal fea-
ture of the rhythm. Tn every case there was a preliminary
fall, abrupt and definite, but usually not so extensive as the
main fall of pressure; this preliminary fall was followed by

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL-MAY-JUNE, 1901.

PLATE XXXi

Fig. 1.— The follicular
artery and its capillaries.
One of the long capillaries
is seen to join a venous
capillary in the periphery
of the follicle; on either
side of the follicle small
veins are seen. Transverse
sections of several veins
are also seen.

Measurements: artery
before dividing. 41 mi-
crons; and capillaries from
8 to 10 microns iu diameter

:^«^«

^-'ny^'^f^f-

(^rr,

Fig. 2. — The origin, course aud distribution of a long follicular
artery.

Measurements: at origin, o4 microns; and before dividing, 31
microns; capillaries in follicle, from 7 to 8 microns.

^5gft-.

■~^&

■A:

Fig. .5.— Two
follicular artery
an artery is seen
end of the follic

follicles with their veins. The follicle on the right shows a portion of a
entering the centre of the follicle. Below the proximal end of the follicle
running parallel to the surface of the gland to turn toward the proximal

le ; here it is lost.

Fig. 3. — An artery arising some distance below the
proximal end of a follicle, running toward the follicle to
turn at a right angle aud run to the centre of the
proximal end of the follicle; here it again turns at a
right angle to enter the follicle, where it divides iu the
usual manner.

^S??Sf^?SQ3:?'SWfS9i%.

%^'

l«^

Fro. 4. — A double arterial siipjily to the follicle.

Fig. 6. Long curved capillaries, c, near the periphery of the follicle.

Apbil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

179

a return to tlie iiimiuil or hijrhcr })ressurc' Ijet'ore the iiriiieipal
i'all oeeiirred. In 4 cases tliere was a distiiiet rise above nor-
mal after the main fall of pressure before the return to the
normal daily oseillations. These variations were not peculiar
to either sex.

A curve constructed on tlie subjective observations of the
sense of well lieini;'. shows ups and downs eorrespondiiii;' to
the marked vai'iations in pressure; the sense of maximum
efficiency of tlu' individual corresponding to the time when
the pressure is hii;]i. and lessened efficiency to the ]ieriods of
low pressure. Tiie observations were carried on iiulopend-
ently of each other. In no case was the change sufficient to
incapacitate the indixidual. The time of low pressure ap-
pears to l)e, in Loth sexes, a jjeriod of increased susce]iti])ility.
If symptoms of any kind are shown they are apt to he given
by the point of least resistance. For exauqile, if a man oi'
woman having a tendency to digestive disturbances, the symp-
toms from the digestive tract are likely to occur at the jjcriod
of l(]\v blood pressure: or when a slight chronic catarrh
exists, as so fre(|uently ha])pens in this climate, there may
be marked increa-e of symptoms from the resjiiratory tract.

In Women the fall in blood jiressure most frecpiently oc-
curs before the menstrual How. the maximum fall being
coincident witli the onset of the flow; there is a gradual
ret^irn to tlie lujrmal mean pressure by the time the men-
struation ceases. Occasionally llie fall oecui-red during the
flr.w.

Wliile true dysmenorrlnea is far too fretpicnf. much of the
so-called menstrual sutfering is not dysmenorrhcea but simply
coincident functional disturbances in other organs, induced,
l)ossibly, by 'the favoring conditions of a lowered general
lilood pressure occurring near or at the time of menstruation,
((.ioodman's restricted definition of menstruation is adhered
to — ^" A periodic sanguineous defluxion from the genital
tract.")

When tile attention is of necessity directed to so obvious a

l)rocess as the menstrual flow, untrained women, especially if
without absorbing occujiation, naturally refer their lessened
sense of w'ell being and diminished sense of efficiency, which
may accompany the lowered general blood pressure occurring
near or at the menstrual flow, to the fnnctiou of nu'iistrua-
tion. When we remendier how firmly fixed is the tradition
that a woman nuist sufl'er and be incapacitated by this normal
physiological function, it is .readily understood how many
women would call the depression due to lowered blood pres-
sure, menstrual suffering.

All statistics, however extensive or carefully taken, arc
likely to exaggerate the percentage of women suffering
fi'om dysmenorrhcea, because the errors just mentioned are
so difficult to eliminate.

The conception that functional disturbances in other
organs are considered and recorded as dysmenorrhcea was
first derived from the study of the clinical data and later
strengthened by the blood-iiressure experiments supple-
mented by tlie notes of the ]ier,sons studied.

The conclusions of this paper would have been impos-
sil)le had my clinical data consisted merely of isolated state-
ments ba.sed on the general impressions, as to their own con-
ditions, of individual women filling out a single menstrual
record, and without a personal acquaintance with, and an
intimate knowledge of, the haliits of life and conditions of
work of the women studied.

Although S]iace forbids detailed acknowledgements at this
time, I wish to state my obligations for many favors received
at Stanford University in the earlier work; to Dr. Howell and
his associates, Dr. Dawson and Dr. Krlanger of the Pliysio-
logical Department of the Johns IIoi)kins ITniversity; to Dr.
Kelly's lilierality and generous encouragement which have
made possible all of the later work. The intelligent co-
operation of my former students and many friends and of
the nu'U and wcunen who have recently given and are giving
so much of their valuable time, has made this work possible.

RETROJECTION OF IIILK INTO TIIK I'AXCKEAS, A CAUSE OF ACUTE IIEM01II!11A(IIC

FANCREATITIS.

I;v W. S. II.\L8TED, M. D.

Mr. T., aged 18, a cor|julenl and robust looking man, Jiad
been subject to attacks of " indigestion," attended with pain
in tlie epigastrium and a feeling of distention, for several
years. These attacks would .sometimes incajiacitate him for
business, lie had a severe attack of this kind la-st Christmas-
tide. He described also attacks of "vertigo," which had laid
him U]) for S or 10 days every spring, with perha]is one ex-
ception, for the past ten years. At the end of April, 1901,
be arrived in Baltimore after a hard railr(ia<l trip of about
S days. On the way, suffering with indigestion, he bought
a two-ounce package of bicarbonate of soda, half of wbieb
lie consumeil. After Inneheon on the dav of liis arrival he

was seize<l (piite suddc^nly with a severe pain in the abdomen;
he was nauseated and expressed his desire to be relieved of
the "gas in the stomach." His physician administered
calomel, and later nux vomica and carminatives. For 2-1:
liours he was relieved; then, -after eating buckwheat cakes,
the pain returned. Occasionally driiddng large quantities
■^of water, he forced himself with difficulty to vomit. He
suffered almost constantly more or less pain for a week, Init
took his meals regularly and slept about as well as usual.
About noon on the Htb of May, the pain became very se-
vere; morphia administered hypodermically three times dur-
ing the afternoon. J grain in all, did not give much relief.

180

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-1S3.

Inhalations of chloroform had to be given. At 9 j). ni. I
was asked to sec him by his attending i)li3'sicians. As
I entered liis bedroom, lie was walking al)out in his
pajamas, excited and iiervous, and his teeth chattei'ing; he
seemed to be in great pain. His pulse was full and regular,
92 tlie first count and 87 the second. When I attempted to
examine him he made an effort to keep quiet but in a moment
had to spring up again. He was sensitive to pressure over
the epigastrium, but not exquisitely, the point of greatest
tenderness being a little above and, I thought, to the right
of the umbilicus. He was "somewhat cyanosed. My atten-
tion was called to the cyanosis by the print of my fingers on
his abdominal wall. His condition was so good tliat I
tliought, with his physicians, he was jirobably suffering from
gall stones. He refused to go to tlie hospital. Hot baths
during the night relieved him, I am told, for the time, but
he had to be chloroformed frequently. In the morning he
was anxious to go to the hospital and was operated upon
immediately after his arrival, about 11 a. m.

Operation. — The cyanosis of the patient was much more
striking as he was laid on the ojierating table, and lie vomited
as he was being antesthetized. The abdomen was not dis-
tended, but the panniculus was very deep. On opening the
belly through the middle line blood-stained fluid escaped and
at once it was noticed that the omentum showed abundant
fat necroses; these necroses were to be seen in the subperi-
toneal fat, in the mesentery, along the lesser and greater
curvatures of tlie stomach, etc. In order to explore more
fully the pancreas and to make sure that a certain hemor-
rhage in the wall of the stomach, near the pyloric end, had
not produced any serious lesion, the omental bursa was rap-
idly opened. Nothing that could be designated as a tumor
mass was made out; the entire region of the pancreas could
be palpated. The tissues over the pancreas were slightly in-
filtrated with blood-stained scrum. The common bile duct,
however, was distended to the size, perhaps, of an index
finger. The presence of a stone in the diverticulum was of
course suspected, and a careful though luirried search made,
but none could bo felt; the fluid in the abdominal cavity was
rapidly sponged out and a gauze pack placed over th(' head
of the pancreas. The abdomen was then closed. The pa-
tient died within 23 hours.

Pain, vomiting, distention of the abdoiiien, sometimes an
clastic swelling in the region of the pancreas, fluid in the
peritoneal cavity, pulse 140 to IGO or higher, cyanosis, col-
lapse-tliese arc the symptoms which the surgeon calls to
mind when he pictures to himself a case of acute hemor-
rhagic pancreatitis, and hence it is that this disease has
so many times been considered acute intestinal obstruc-
tion. My patient was strong, restless and walking about
the room, not collapsed; his pulse was 92 the first count, 87
the second; the abdomen was not only not distended but.
according to the patient, had greatly diminished in size during
the few weeks preceding this illness; the reduction in the size
of his waist, as evidenced by the considerable space between
the band of his trowsers pnd his abdominal wall, was a matter

which ajiparcntly gave him some concern, for he referred to
it more than once. Vumiting, it' present, was so inconspicu-
ous a .symptom that it had not been noticed; the ]jatieiit had
perluqis 3 or -1 times tickled his pharynx because he tluiught
it relieved him to gag and bring up a little mucus from his
stomach. When I saw him about 13 hours before the o])era-
tion and again an hour before it, pain in the epigastrium and
slight cyanosis were his only symptoms. But the pain must
have been intense and seemed greater than I had ever seen it
in cases of gall stone. I had the misgiving that I was in
the presence of an unfamiliar affection and was prepared for
a surprise when I opened the abdomen; and yet acute pan-
creatitis did not occur to me, my conception of the clinical
picture was so different. But I shall not soon forget this
case; the excruciating pain in the epigastrium and the cy-
anosis; altogether, a clinical picture difEerent from anything
that I could recall. To save my colleagues and students the
humiliation of making the same mistake, I have thought
that it might be well to represent graphically the only sign
which this obseurc case ])resented, the white print of finger-
tips in a slightly cyanosed field just over the site of greatest
pain. Attacks of acute hemorrhagic pancreatitis, mild and
severe, are probably much more common than is generally
supposed, and I am sure that the clinical picture is suffi-
ciently definite to be easily recognized by the general practi-
tioner.

The autopsy was most carefully made by Dr. Opie, whose
description of it will follow. The .stone, which I could not
find in my hurried search at the operation, was almost too
minute to have been detected under the circumstances, and
even at the autojisy it was only after prolonged handling and
probing of the papilla itself outside of the body that the
presence of a stone was determined. Opie has found that
gall stones have been present in the majority of the more
recently reported cases of acute hemorrhagic pancreatitis.
In some instances they were, imdoubtedly, not carefully
searched for, in a few they may have been overlooked and in
others they may have passed the papilla, having been arrest-
ed in the diverticulum long enough to produce the lesion in
the pancreas. If it is true, as this case and Opie's experi-
ments recorded below prove almost beyond question, that
acute hemorrhngic j^ancrcatitis may be caused by liile retro-
jected into the pancreatic duct, the inference that milder
lesions and subacute and chronic changes may be produced
in the pancreas by the mere presence of bile in its ducts is
natural. The fact that the entire pancreas is not always or
even usually involved, normal areas being found here and
there among the hemorrhagic ones, makes it seem not un-
likely that quite small patches may at times be afEected and
that the symptoms after very limited involvement might be
overlooked or misinterpreted. Epigastric pain, rapid pulse,
nausea, vomiting and possibly hematemesis coming on either
soon or long after operations upon the common duct might
in some instances be attributable to lesions in the pancreas.

The Mechanism, — The arrangement of the parts concerned

Apeil-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

181

in the production of acute hemorrhagic pancreatitis reminds
me of the liydraulic ram in its primitive form. The ductus
clioledochus is the feed pipe, tlie pancreatic duct tlie deliv-
ery pipe and the calculus the ball valve or stop cock.
Although I know of no experiment to determine the force
with which bile may be ejected from the gall bladder, it is
conceivable that the sudden and complete interruption of
the flow of bile during digestion by a calculus might give
rise to a retrojection spurt of considerable volume and ve-
locity. But whether this force is considerable or not, since
the pancreatic juice and the bile are secreted at almost the
same, quite low (3j^ini. of water) pressure, it would prob-
ably be suflicieiit, as Dr. Opie will show, to drive the bile
into the pancreatic duct under the proper conditions.

Why is pancreatitis hemorrhagica acuta such a rare disease?

1. That bile may be retrojeeted into the pancreatic duct,
the stone must be (a) too small to occlude the pancreatic duct
or interfei'e with the force of the jet aud at the same time
(6) too large to pass the papilla.

2. A narrow papillary orifice, such as we found in my case
(a rare condition), would predispose to this affection, because
many stones small enough to fulfill (a) the first condition are
too small to fulfill (b) the second.

3. One calculus would be more likely to cause the pan-
creatitis than several, for other stones in this duct, unless
very small, would weaken the force of the bile-spurt which
drives the ball valve against the papillary orifice. I have
elsewhere called attention to this fact.'

4. The gall bladder must perhaps be normal or nearly so;
not thickened, shrunken or weakened by inflammation.
Accordingly, one must have a calculus or calculi which have
produced insignificant changes, if any, in the walls of the
bladder.

5. The anomalies which Dr. Opie will consider protect a
certain proportion of cases.

6. A predisposition may be necessary, as is given by adi-
posis and excessive use of alcohol.

Apropos of what I have said as to the possibility of mild
attacks of hemorrhagic pancreatitis after gall stone opera-
tions. Dr. Finney has just told me the story of a most inter-
esting and perhaps not wholly unique case. Four months
ago he did a choledochotomy for 2 large soft stones in the
common duct. The duct was enormously dilated, the gall
bladder atrophied. The stones were almost as mushy as
damp salt, and crumbled to pieces in the duct. The detritus
was removed with extreme care and the duct afterwards re-
peatedly flushed with the physiological solution; notwith-
standing this it seemed to Dr. Finney that some grains
still remained in the duct. The incision into the common
duct was sutured and the convalescence was entirely une-
ventful except for a trivial leakage of bile beginning
about the 7th day p. o. A few days ago, when in robust
health, the patient was seized with excruciating pains in the

' Halsted. Contributions to tlie Surgery of tl\e Bile Passages. Tlie
Johns Hopkins Hospital Bulletin, .January, 1900.

epigastrium, unlike any that he had ever experienced. Dr.
Fiuney was telegraphed for promptly and reaching the patient
in a few hours found him vomiting, collapsed, cyanosed and
suffering pain so severe that morphia in large doses did
not control it; tb.e pulse was aliout 160, pressure over the
pancreas was unendurable, the abdomen was distended.
Acute pancreatitis was suspected, and operation, considering
the collapsed condition of the jiatient, deemed inadvisable.
The following day the patient was brought to the Johns Hop-
kins Hospital, his condition was greatly improved and 48
lioui's later he seemed perfectly well.

Is it not probable that in this case one of the fragments
increased in size may have been responsible for the attack?
Was the fragment passed? What were the lesions in this
attack ? Acute pancreatitis just beginning to be understood
will probably soon become a household word.

Trealmeni. — We must learn to make the diagnosis
pronijith-, and to distinguish gall stone attacks per se from
those attended with pancreatic complications.

To search for and remove the stone in the diverticulum
as soon as possible after the appearance of the first symp-
toms would be the correct procedure in some cases if the
true nature of the attack could be recognized early enough.
If this patient of mine had been operated upon and the
stone removed at some time prior to the onset of his severe
symptoms, perhaps at any time within the first seven or
eight days of his illness, it seems probable that his life could
have been saved. Without operation there was little if any
hope for him, for the conditions responsible for the lesions
would have persisted. It was evident at the operation that
the common duct was obstructed but the patient's condition
absolutely eontraindicated prolonged search for the cause,
which probably could only have been determined by open-
ing the common duct or the duodenum, so minute was the
calculus. Operation should not be undertaken upon cases in
collapse, but the bloody fluid, probably highly toxic,' may
he hastily evacuated by laparotomy (local anaesthesia) in
cases too ill for radical operation.

Of 25 cases of acute hemorrhagic pancreatitis operated
upon only two have recovered,' a case operated upon by me
eleven years ago" and Hahn's case recently reported.*

In his recent article Prof. Hahn expresses a desire to learn
if the operation performed by me in the case which recov-
ered was prolonged by the usual search for some cause of
intestinal obstruction, and the hope that, in future, inocu-
lations of culture media will be made from the blood-stained
abdominal fluid. It gives me pleasure to be able to reply
and to state that fat necrosis was at once observed, the
diagnosis promptly made and the operation, therefore, prob-
ably a short one: drainage was not employed. This patient
is alive and apparently well. In the second case, inocula-

sHahn. Deutsche Zeitsehr. f. Chir. Brt. 8.5. Heft 1.
3 Kortc. Die Chirurgisehen Krankheiten unci die Verletzungen des
Pankreas.
* Hahn, 1. c.

182

.JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

tious from the bloody abdomimil Ihiid wore made, aud witli
negative results.

It seems not improbable that, as Hahii states, the rapid
evacuation ol' the bloody tluid in the abdominal cavity
may in some cases be benelicial. llahu believes that
this fluid is highly toxic and perhaps inlectious, and empha-
sizes the fact, e.\emplified by one of the cases which he
reports, that large retroperitoneal extravasations of blood
cause incomparably less disturliaiice than we see in these
cases ol' hemorrhagic pancreatitis in which the loss of blood
is insigiiilicant. I had read llalurs article only a few days
prior to the o])eration upon tliis case and was acting
u[ion his suggestion, but coming so quickly upon the di-
lated common duct 1 lelt myself compelled to make a hur-
ried scari'h for the cause of the obstruction. I have little
doul)t that my operation hasteiu'd the death of the [latient.

If a stone in Venter's diverticulum was the cause of the
pancreatitis in my first case, the one that recovered after
oj)eiatiiin, we must conclude that it passed the |ia)iillii, proli-
alily dnring the attack, for it had [u-oduced no symptoms
fronr the time of the operation, May. 1890, until June, 189."),
when he was examined in the hospital by Dr. F)loodgood.
I fiml that I misinformed Dr. Korte' when I wrote hiui that
my recovered case had had a subsequent attack. The attack
referred to oecu"]i'e(l in aiiotlier case, one of suppui-ative pan-
creatitis, operated upon and cuied by my associate. Dr. I""inney.

'' Kitrti* ; Die Cliifu ri;is(!lii-'ii Ki':tnkliriti*n iiiid die \'t*ii('1zniii:"i-ii dcs
?:iulirciis. Deutselii- Cliir. IS'.IS, ji. 171.

TTTE ETIOLOGY OF ACUTE HEi\IOKRTIAGIC
PANCKKATITJS.

JjY Eugene L. Orn:, M. D.
fiislruf/iir ill Paihologij, Johns IlopMn.i Uiiiirrsilji.

(Fi-inii III, l;il/i„lv,/ir,i/ Liihiiiiitfiri/ of l/ii .h.hiis lli'iikuis C.iiviKil,/ ,n,d
J[..s,nl.,l.)

Pathological Eepoht.

In many reported cases of hemorrhagic and of gangrenous
pancreatitis symptoms of cholelithiasis have been associated
with the fatal illness and at autopsy calculi have been found
in the gall bladder or in the bile jjassagos. In a recent arti-
cle ' I collected from the literature thirty-one cases of this
character and described an additional instance. In eight of
these cases, including the one which I reported, a gall stone
was found at autopsy lodged near the orifice of the common
bile duct or there was evidence that one had shortly before
death occupied this position. Since the common bile duct
and the duct of Wirsung unite to form the diverticulum of
Vater before they enter the intestine, a calculus so located
might occlude both ducts. In the greater number of these
collected cases though calculi were found at autopsy, none

' Opie. Amci'. Jmir. of tlie Med. Se

I'.Kll,

exxi. [1.

were situated near the junction of the two duets. Neverthe-
less since, as was pointed out, death with intense hemor-
rhagic inflammation of the gland has in several instances fol-
lowed within forty-eight hours the onset of symptoms and a
ealeulus has been found near the duodenal orifice of the eom-
miin duet, it is readily conceivable that a stone tein|)oi'arily
lodged in the position indicated might produce grave altera-
tion of the gland before its final expulsion into tlie duode-
num. In seven of the thirty-one cases death followed the
onset of symptoms, intense abdominal [)ain, vomiting and
profound coflapse, within forty-eight hours, and at autopsy
the jiancreas was the seat of hemorrhagic infiltration. In
seventeen instances in which tlu' fatal illness was of longer
duration, seven days to four months, the paiu-reas was gan-
grenous and there was often evidence of pi'evious hemor-
rliage. There can be little doubt that gangrencuis p;ini-r('a-
titis is a late stage of the hemorrhagic lesion.

That acute pancreatic disease is fre<pieiitly iissociaied with
ebolelilhiasis has been conliiined by cases ie[iorted since the
preparation of the article referred to. The two conditions
were |)resent in three cases recently described by Lund," in
two by Bryant' and in one by Stockt(Ui and Williams,' by
Struppler ' and by Ilahn.'' The relative frequency with
which acute pancreatitis is accompanied by cholelithiasis is
dillicult to estimate. In some cases the lesion has been
tbagiiosed upon the operating table and, no autopsy being
obtained, the condition of the bile jiassages has not been
determined. In a very large proportion of the cases the
nntojisy report is so meagre that the presence or aljsence
of gall stones is not evident. Lund records the relatively
large number of six cases of acute pancreatitis, one siqipnra-
five, five hemorrhagic or. hemorrhagic and gangrenous. Two
of the five cases he describes as hemorrhagic peripancreatitis.
ill three of these live cases the gall bladder or the bile pas-
sages contained small calculi in large number, wliile in the
remaining two no autopsy was obtained. In the two cases
reported by liryiint hemorrbngic pancreatitis was associated
with gail stones. In only one of the five cases of Ilahn were
gall stones present, but in one of his cases hemorrhagic infil-
tration of the gland followed a pistof shot wound and in
another recovery followed operation, (lall stones were, there-
fore, present in six of eight cases with autopsy described by
three writers who have recently reported more than one
instance of the disease.

In view of the fact that in several instances a calculus has
been found at autoj)sy so lodged as to occlude the jianereatic
duct, there can be no douljt that the frequent association of
the two conditions is the result of an etiological relationship.
The common liile duct and the larger pancreatic duet lie
side by side as they penetrate the wall of the duodenum and
are often separated near their junction only by a thin mem-

'I^iiiid. Boston Med. and Surg. Jour., 1!>00, exliii, p. M?y.

' Hrynut. Liinoet, IflOO, ii, p. lo41.

■•Stoclcton .ind Williams. Philadelpliia Med. .Tour., I'.lOd, vi, p. (;4!l.

'•Struppler. Dcutsehe Arcli. f. Ulin Med., liieo, Ixix, p. JOC.

«Hahn. Deutsche Zcitschr. f. Cliir., Umo, Iviii, p. 1.

Apeil-Mat-Jdne, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

183

branous septum, while before entering the duodennm at the
suiumit of the bile papilla they unite to form a short chan-
nel, the diverticulum of Vater. From a study of the case
previously reported it seemed not improbable that a calcu-
lus lodged in the common bile duet near its termination
might cause partial occlusion of the pancreatic duct and sub-
sequent changes in the pancreas as the result, possibly, ol'
bacterial invasion. This case, as well as those recorded in
the literature, alforded, however, no explanatirm of the
pathogenesis of hemorrhagic inflammation. Tlie autopsy
recently performed upon the case described Ijy Dr. Halsted
has dciiionslruted a mechanism by which this lesion is pro-
duced.

Aulopsij. — The body, which is still warm, is tliat id' a large
man with very abundant subcutaneous fat. The skin has
a bluish cyanotic appeiU'ance. Passing downward from the
right costal margin to a point 10 cm. from the symphysis
pubis is a longitudinal incision, closed in great part by sub-
cutaneous silver wire sutures. Crossing tiie epigastric region
and meeiiug the hrst at right angles is a second incision. At
their angle of junction the wound is unclosed for a short
distance aiul gauze packed aboid by rubln'i- protective passes
into the abdonunal cavity.

The jiei'itoneal cavity contains a moderate excess of l)iood-
stained serous lluid. The general peritoneal surface is
smooth. l<'at is present in very great amount in tlie omen-
tum, in rnml (it the peritoneum of the ant<i-i(ir alidoniinal
wall below tlie umbilicus, in the mesentery, in the retroperi-
t(}neal tissue and as appendices epiploic^ upon the surface ol
the large intestine. Studding the fat in the various situa-
tions named and conspicuous upon its translucent surface are
small usually round opaque white, areas 2 to 3 mm. ^n diam-
eter, often surrounded by a narrow zone of injection: They
ai-e sujjerficially situated and extend usually less than 1 mm.
below the surface. They are most abundant in the omentum
and in the retroperitoneal fat adjacent to the pancreas. The
gauze drain previously mentioned passes between the stomach
and the transverse colon and lies in contact with the retro-
peritoneal fat immediately below the head of the pancreas.
Here tlie tissue has a reddish-black discoloration.

The pancreas is represented by a blackish sw(dleu mass
extending from the descending part of the duodenum to the
spleen. The fat in contact with its splenic end has a similar
blackish color and is soft and friable. The pancreas is
greatly increased in size, is irregularly cylindrical in shape
and measures 5.2 cm. antero-posteriorly, 5.5 em. from above
down, and 16 cm. in length. The anterior surface is smooth
and has an almost uniform black color in places with a red-
dish tint. On section the gland substance is found to be in
great part transformed into black and reddish-black material.
The head of the organ for a distance of 2.5 em. from the
duodenum is firm, gray yellow, with well marked lobulation,
and has the appearance of the fresh normal pancreas. Tissue
« hicli is in immediate contact with this well preserved gland
substance is soft and black in color, mottled here and there
with small areas of dull red; gland lobulation is still very

obscurely marked. The distal half of the organ shows a
similar mottling of black and reddish areas with in places
small islands of yellowish, relatively preserved tissue. The
largest of these, which is of reddish-yellow color, gradually
passing into the surrounding reddish-black, is 1.5 cm. in
diameter and is situated near the middle of the body. At
the splenic extremity is a slightly smaller mass of intact gland
substance. On opening the splenic vein where it lies in
contact with the jiancreas the intima is found to lia\( a mol-
lled yellow, blackish and red appearance, due to cbanges iu
the underlying tissue. Occupying a portion of the lumen is
a mixed red and yellow thrombus mass, fifin in consistence
and adherent to the intima.

The duodenum was opened and the common orifice ol' tlir
bile and pancreatic ducts examined. The papilla is promi-
nent but its orifice is of small size measuring 1 mm. in
diameter. The common bile duet which near its termination
is completely embedded in the substance of the pancreas is
slightly distended. By very firm pressure on the gall Idadder
.-everal drops of liile can be squeezed with dithculty into the
duodenum. The gall bladder when opened is found to eon-
tain a moderate amount of viscid blackish bile; no concretions
are present. The termination of the pancreatic duct, which
is surrounded by the well preserved pancreatic substance in
contact with the duodenum, was exposed by dissection and
found to unite with the common bile duct 10 mm. from the
summit of the bile papilla. A probe passed dow^n the com-
mon duct was stopped -1 mm. from the latter point, and it was
not possible to touch it with a second probe passed into the
narrow orifice. Careful examination disclosed a small gray-
white, very firm concretion 3 mm. in diameter, snugly filling
the diverticulum of Vater from which it could not escape
through the narrow duodenal orifice. The pancreatic duct,
where it passes through the intact tissue of the head, is like
the common duct stained firight green with bile.

The heart and lungs are -apparently normal. The liver
weighs 1350 grins. The surface is smooth and of yellowish
color; upon the upper surface of the right lobe are conspicu-
ous slightly depressed dull red areas which are irregular in ■
shape, the larger about 2.5 em. across. The cut surface of
the organ has a bright yellow color, the periphery of the
lobules being golden-yellow, the central part reddish. Cor-
responding to the superficial red areas the liver substance has
a similar dull red appearance, the periphery of the lobules
being marked by narrow yellow zones. Such altered tissue
has at times an irregularly wedge-shaped outline and within
it are found portal veins distended and plugged with red
thrombus material. Following the vein in one of these areas
toward the main portal trunk, the thrombus stops abruptly
and near its end is of yellowish-white color, representing
probably embolic material from the thrombosed splenic vein.
The spleen is not enlarged and weighs 140 grms. The
organ is flaccid but fairly firm in consistence.

The stomach contains a small amount of blackish semi-
fluid material. The duodennm and remainder of the small
intestine contain similar material. The kidneys, weighing

184

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

together 290 grms., appear to be normal, except for the
presence of opaque yellow striations near the apices of the
pyramids. The adrenals, the bladder, the seminal vesicles
and the prostate are normal. Upon the intima of the aorta
are a few slightly raised opaqiie yellow patches of small size.
The urine contained in the bladder does not reduce Fehling's
solution.

Microscopic examination of the pancreas. — A section passing
through tlie line of demarcation between the intact paren-
chyma in the head of the gland and the adjacent necrotic
tissue shows a very abrupt transition from the one to the
other. On the one side the pancreatic tissue is well pre-
served, the secreting cells are normal in appearance and their
basal zone stains deeply with haimatoxylin, while islands of
Langerhans are fairly abundant and appear to be normal.
The loose interlobular areolar tissue is everywhere infiltrated
with red-blood corpuscles; polynuclear leucocytes are present
in large number and often form collections of considerable
extent. Eosinophilic leucocytes are numerous and fibrin is
abundant. Between the acini are a few polynuclear leuco-
cytes. Within the margin of the intact tissue are several
small areas where the parenchyma is undergoing necrosis.
The secreting cells no longer stain with hfematoxylin, but
assume a homogeneous clear pink color with eosin; the nuclei
which are still preserved are much smaller than those of the
normal cells and unlike the latter are irregular and distorted
and stain homogeneously. Small hemorrhages have taken
place into the interacinar tissue of such an area, and poly-
nuclear leucocytes are present in moderate number. Nearby
in similarly localized areas the process is more advanced and
the parenchymatous cells are replaced by formless material
which staining faintly is mingled with a few nuclear frag-
ments and is densely infiltrated with polynuclear leucocytes
and red-blood corpuscles.

The transition from relatively normal parenchyma con-
taining a few islands of necrosis to wholly necrotic tissue is
very abrupt and is marked by a zone composed of nuclear
fragments, polynuclear leucocytes, red-blood corpuscles and
fibrin. That part of the section which corresponds to the
black and reddish-black material seen macroscopically is ne-
crotic, nuclei are no longer present and though the architec-
ture of the gland is still obscurely definable both parenchyma
and connective tissue stain only with eosin. At intervals in
areas of varying extent the tissue has a dark brown discolora-
tion due to the presence of brown pigmented material which
appears to be changed blood.

Sections from the body and tail of the organ present the
appearance described above. In the intact tissue of the tail
well preserved islands of Langerhans are particularly num-
erous. In a section from the body nuclei still persist imme-
diately about an artery, though the surrounding tissue is
universally necrotic. Its endothelial cells are swollen and in
places are almost cubical. In the media and adventitia, of
which the vasa vasorum are preserved, polyaiuclear leucocytes
are very numerous.

In sections stained by Weigert's method for the demon-

stration of fibrin was noted a histological detail inconspicuous
by other methods. Capillary vessels in the living tissue near
the margin of necrosis as well as in the immediately adjacent
necrotic part liave undergone hyaline thrombosis and form
conspicuous deep blue, often branched, lines as though in-
jected. Examination with high magnification demonstrates
at times a close meshwork of fibrils in these vessels. In
sections stained with hannatoxylin and eosin their contents
take a homogeneous briglit pinkish-red stain and red-blood
corpuscles are no longer seen, as in adjacent capillaries.

lu sections stained for bacteria with niethylene-blue, with
gentian violet, and by Weigert's method, none were dis-
covered.

Bacteriological e.vamination. — Plate cultures in agar-agar
were made at autopsy from the heart's blood, peritoneal
cavity, pancreas (aerobic and anaerobic on hydrocele agar-
agar), gall bladder, liver, spleen, and kidney. They were
studied by Mr. V. II. Bassett to whom I am indebted for the
following report. Cultures from the heart's blood, spleen,
and gall bladder gave negative results. The anaerobic culture
from the pancreas showed no growth after an incubation of
seventy-two hours. The aerobic agar-agar plate from the
pancreas contained at the end of twenty-four hours a single
superficial colony of a pigment forming coccus whose cul-
tural characters indicated tliat it was a contamination from
the air. The streptococcus pyogenes and the staphylococcus
epidermidis albus were isolated from the peritoneal cavity.
Tlie colon bacillus was present in cultures from the liver and
kidney.

Anatomiral diagnosis. — Cholelithiasis; calculus impacted in
the diverticulum of Vater partially filling it and occluding
its duodenal orifice. Aeule hemorrhagic pancreatitis; dis-
seminated abdominal fat necrosis. Partial thrombosis of the
splenic vein; embolism and thrombosis of branches of the
portal vein.

The preceding autopsy has disclosed a condition which
explains, I believe, the pathogenesis of those cases of acute
hemorrhagic and gangrenous pancreatitis which are associated
with gall stones. The diverticulum of Vater was 10 mm. in
length. Lodged at its apex, blocking its duodenal orifice,
was a small calculus only 3 mm. in diameter, but too small
to pass the narrow opening. Though it occluded the duo-
denal orifice of the diverticulum it was so small that the
orifices of the common bile duct and pancreatic duct were
unobstructed. The two ducts were therefore, converted into
a continuous closed channel from which it was not possible
for either bile or pancreatic juice to escape.

On dissecting the pancreatic duct where it passed through
the unchanged parenchyma in contact with the duodenum it
was found, like the bile duct, to be stained bright green with
bile. Where, as in this case, the two ducts become a closed
channel, the entrance of bile into the pancreas or of pancreatic
juice into the bile passages would depend upon the relative
pressure in the two ducts. The pressure at which bile and

Aphil-Mat-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

185

paneroatic juice are secreted being small, any slight difference
tliat might exist would be overcome by the gall Ijladder, a
ijiuscular organ Avhicli at intervals forces bile in considerable
quantity along the common duct.

A small calculus only partially tilling the ampulla of Vater
can convert the two duets into a continuous channel, while
a larger stone might simultaneously oTistruet the duodenal
orifice of the diverticulum and the orifices of the two ducts
wliicli enter it, thus damming liack bile and pancreatic juice
upon their respective glands. In the present case, as pre-
viously mentioned, the diverticulum measured 10 mm. in
length, the calculus 3 mm. in diameter. In many cases of
hemorrhagic and gangrenous pancreatitis gall stones found in
the gall bladder and bile passages at autopsy have been small
and are often described as pea-sized. This statement is made
in the reports of Pay,' Cutler,' Ivennan,° Simpson," Chiari "
(two cases), Smith," Ehrich," Fraenkel," Korte," Morian,'"
Eolieston," Grawitz," Opie,'° Bryant =° and Lund" (three
cases).

Anatomical peculiarities of the diverticulum of Vater
miglit favor or prevent' the conversion of the two ducts into
a closed channel. The description of the ampulla given by
Sappey,™ Testut," Henle'* and Quain '° does not differ materi-
ally. It may be described as a somewhat conical cavity into
whose base open the two ducts; the apex situated at the sum-
mit of the diverticulum is their common duodenal orifice.
Its length varies from 6 to 7 mm. according to Testut, from
7 to 8 mm. according to Sappey. Occasionally the two ducts
have no common channel, but open by separate orifices upon
the summit of the bile papilla. Claude Bernard '" described
a variety of termination which has since been observed.
The bile duct is prolonged as far as the mucosa of the duo-
denum, upon which it opens by a circular orifice. The
terminal part of the pancreatic duct embraces the bile duct
like a gutter and its. orifice has the outline of a crescent.
Where the ampulla is very short or the two duets open sepa-
rately into the duodenum it is evident that an impacted
calculus could not render continuous the lumina of the two
ducts.

'Day. Boston Med. ;iiul Surg. Jour., ISOi, cxxvii, p. .563.
* Cutler. Ibid., 1S95, cxx.xii, p. 354.
"Kenn.in. Brit. Med. Jour., 1806, ii, p. 1443.
'"Simpson. Ediuburiili Med. Jour., 1897, ii, p. 24.5.
" C'liiari. Wiener Med. Wocliensch., lS7(i, xxvi, p. 3iU ; Ibid., 1880,
XXX, pp. 139, 164.

I'Smitli. Brit. .Med. Jour., 1897, ii, p. 468.

"Elirich. Beitrii^e z. lilin. Cbir., 1S98, xx, p. 316.

" Fraenkel. Miiuch. med. Wochenscli., 1896, xliii, pp. 813, 844.

isRorte. Arcli. f. klin. Cliir., 1894, xlviii, p. 721.

".Morian. .Miinch. med. Wochenscli., 1899, Ixvi, p. 348.

" Ilolleston. Trans. Path. Soc. of London, 1893, xliv, p. 71.

'«Grawitz. Miincli. med. Wochensch., 1899, xlvii, p. 813.

lii in 81 x,„. ,.if

■^■Sappey. Traite d'anatomie descriptive. Paris, 1889.
'■'Testut. Traite d'anatomie humaine. Paris, 1894.
=* Ilenle. Handbuch der Systematischen Anatomic des Mcnsclien.
Braunschweig, 1873.

■'■Quain. Elements of Anatomy. London, 1896.
'5 Quoted by Sappey.

I have recently examined the diverticulum of Vater in a
small number of cases available. In three specimens (Nos.
3, 11 and 13) the ducts opened into the intestine by separate
orifices. The following figures represent the length of the
ampulla in these cases:

5 mm.

No.

.... 5 mm.

(; "

... 0 "

4 "

.... 5 '*

. . . . 7 "

7 . . . .

... 10 "

.... 7 "

... .5.5"

Jo. 10 ...

3.5

" U

" 13...

6.5

" 13

... 0

" 14 . . .

. ..55

" 15

1.5

" 1()

" 17

No. G is from the case previously reported, No. 7 the one
described in the present article. The figures are cited to
show that the length of the so-called diverticulum varies
considerably.

Another anatomical factor of considerable importance is
the size of the duodenal orifice of the ampulla. Ilyrtl " states
that this opening is narrower than the lumen of the gall duct
at any point or is at least less distensible so that gall stones
often remain here im]iacted. In the autopsy describetl the
opening measured only 1 mm. in diameter. In most in-
stances it measured 2 to 2.5 mm.; in specimen No. 9 the
diameter was 4 mm.

EXPEHIMENTAL StUDT.

Hemorrhagic pancreatitis has been produced experimen-
tally by the injection of a variety of irritating substances into
the iiancreas, but no attempt has been made to reproduce the
lesion by the use of bile.

Thiroloix "' injected several drops of deliquescent chloride
of zinc into the duct of Wirsung in a dog. Death occurred
suddenly after a short interval and the pancreas was repre-
sented by what appeared to be a blackish clot. Hlava " in-
jected artificial gastric juice into the pancreatic duct. This
fluid, containing hydrochloric acid in the proportion of 1 to
1000, caused death in three days; the pancreas was hypersemic
and in the fat of the omentum and of the mesentery were
numerous foci of necroses. Death on the tenth day followed
the injection of 5 cc. of artificial gastric juice with hydro-
chloric acid 4 to 1000; the pancreas was the seat of hemor-
rhagic infiltration and the omentum and mesentery contained
foci of fat necrosis. He suggests that in human cases hyper-
acid gastric juice may be forced by antiperistaltic action of
the intestine into the pancreatic duct, thus causing the con-
dition. Hlava has produced a hemorrhagic lesion of the
gland Iiy injecting cultures of the bacillus coli communis,
lincilliis lactis aerogenes, and bacillus capsulatus of Fried-
liiuder, but thinks that the change is the result of the acid
products of these organisms.

"riyrtl. ITandbuch der Topographischcn Anatomic. Vicuna, 1882.
'"Thiroloix. Quoted by Carnot (see below).
"Illava. Quoted by Flexner (see below).

186

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

Oser '" records the injection of 4 cc. ol ^'u normal sulphuric
acid solution into the pancreatic duct of a dog. Deatli fol-
lowed in twenty hours. In the duodenal part of the gland
was a hemorrhagic area the size of a pea where the tissue was
destroyed and its structure no louger recognizable. By tlie
injection of tiie fi'rment, papaine (0.2 grnis. in 30 cc. of water),
inio |]ie duel of a ilog, C'arnot '" caused the deatli of the
animal in twenty-five hoiirs; the pancreas was every wlierc
inllltrated with blood but there was no necrosis of fat.
Smaller doses did not produce hemorrhagic lesions. The
same wi'ilcr pi'odueed hemorrlnxgic pancreatitis by the injci--
lidii 1)1' the diphtheria toxinc into the pancreatic duct of a
rabbit. A suspension of the bacillus coli connnunis (12 cc.)
caused a similar lesion fatal in twenty-four hours. Subse-
quent injections of the same organism caused inllanimatory
rliaiigcs wilbnut hemorrhage.

More varied ami successful experiments have been per-
formed by Dr. Klexner^" in this laboratory. In ten experi-
ments pei'l'iirnied ujiim ddgs bydnu-hloric acid varying in
strength in dilfcrent instances from 0.5 to 2 per cent, and
in amount from 3 to 8 ec, was injected into the pancreatic
dui't. In six instances there resulted hemorrhagic inflam-
mation of the gland, accompanied in five by focal fat
lu'croses. In three of these cases death followed the oper-
ation within twenty-four boni-s; in [wo the animals wei'c
killed. In tlie remaining experiments purulent or chronic
inteistitial inflammaticni resulted. Hemorrhagic lesioms were
produced in two dogs liy the use of nitric acid (1 cc. of a 2
per cent solution and 5 cc. of a 1 per cent solution); in one,
by the use of chromic acid (8 cc. of a 1 per cent solution).
In a second series of experiments sodium hydroxide solution
(21) to .5 cc. of solutions varying in strength from 1 per cent
to 2 per cent) was employed. Hemorrhagic lesions resulted
in three cases and were accompanied by fat necrosis in at
least two. Suspensicnis of bacteria were used in a third series,
llenmrrhagic inflammation was caused liy the bacillus pyo-
ej^aneus and in three experiments by the bacillus diphtheria'
but was unaccompanied by definite fat necrosis. In two ex-
|ieriinents the lesion followed the injection of 5 cc. of a 2
[ler cent solution of formalin into the duct and was associated
with fat necrosis.

The experiments cited show that a variety of substances
injected into the duct of the pancreas cause hemorrliagic in-
flannnation. How far they can he used to explain the patho-
genesis of human cases is doubtful. The suggestion of Illava
that gastric juice may be driven by antiperistaltic action of
the intestine into the duets is not supported by any evidence.
The relation of hemorrhagic pancreatitis to bacterial invasion
from the intestine has not been demonstrated. The condi-
tion observed in the autopsy described has suggested a mech-
anism by wliich an irritating substance can make its way into

3" Oser. Die Erlii-aukuugeu des Panlireas. Nntliuagel's Spec. I'ntli. u.
Ther., xviii, ii, p. 2S6. Vienna, 1S'.)S.

3' Carnot. Paris Tliesis, 189S.

■'■ Flexncr. Contrilmtiiius tn the Science of Medicine, Dedicated to
Wm. H. Welcli, M. D., p. 74;). Baltimore, I'.IOO.

the organ. Can the hemorrhagic inflammation observed in
human cases and produced in animals by means of various
irritants be reproduced by the injection of bile into the
pancreatic duct?

In the following experiments the duodenum of dogs was
opened for a distance of several centimetres opposite the
larger pancreatic duet. Tlic blunt pointed nozzle of a syringe
was inserted into the orifice of the duct and bile obtained
from the same or from a second dog was injected into the
organ. The ojierations were performed with the usual anti-
septic precautions and the duodenal wound was closed by
submucous nuittrcss sutures. I desire to express my thanks
to Mr. Bassett, Mr. Haskell and Mr. W. Marshall for assist-
ance in the performance of these operaticuis.

Experiment 1. — Into the larger pancreatic duct was injected
■") cc. of bile obtained from a second dog. The animal was
killed seven days later. The peritoiu'al cavity contains a
small anu)unt of bloody Hnid and the surface is injected.
1'lie large and several loops of the small intestine are firndy
adherent to the splenic arm ol' the pancreas, and on separating
them are exposed pockets containing very thick viscid fluid
ol' dull red C(dor. The walls of these pockets have in places
the opaque white aiipearance of necrotic fat. The splenic
]iart of the gland and the duodenal part, above the duodenal
orifice of the main duet, is firm in consistence and both
ujion the surface and on section shows a mottling of opaque
yellowish-white areas se])ai'ated by dec]) hemorrhagic red.
Over a considerable area at the junction of the duodenal and
splenic parts of the gland the tissue is almost uniformly
grayish-yellow and is in places softened and disintegrated.
Cultures and coverslips from the peritoneal cavity and from
the substance of the pancreas contain no bacteria. Micro-
scopic examination of the splenic and duodenal parts of the
gland show that wide areas of parenchyma including entire
groups of lobules are necrotic and the -secreting cells, whicli
have a homogeneous hyaline appearance and are stained
deeply with eosin, contain no nuclei. At the margin of such
areas red-blood corpuscles and polynuclear leucocytes are
present in great number and fibrin is abundant. In places
the bodies of the secreting cells have been converted into
formless detritus mingled with red-hlood corpuscles ami leu-
cocytes. The interstitial tissue may be implicated in the
general necrosis but often it has undergone very active pro-
liferation and has in small part replaced the disintegrated
acini. Islands of intact parenchyma still persist in places
and are surrounded by newly-formed fibrous tissue, con-
taining red-blood corpuscles and polynuclear leucocytes.

U.rperimeiit 2. — Bile (.5 cc.) from a second dog was injected
as before. The animal was killed at the end of five days.
Lightly adherent to the part of the pancreas which is in eon-
tact with the duodenum are several loops of small intestine.
In the omental fat are several opaque white areas of fat
necrosis, while near the splenic extremity are several incon-
sjiicnous foci of a similar nature. In the duodenal part of the
gland in the neighborhood of the orifice of the larger duct
for a distance of 3.5 cm., there is extensive henun'rhagic infil-

Apeil-May-June, 1901. J

JOHNS HOPKINS HOSPITAL BULLETIN.

187

tratiou separating islands ui' paruuchyma. In places the
gland substance is soft and of gray necrotic appearance. The
.splenic part is lirm in consistence and at several points are
areas of hemorrhagic inliltration. Microscopic examination
of sections from the hemorrhagic duodenal part shows wide
areas of necrosis implicating both lobular and interstitial
tissue. The pareiiehynuUous cells are hjaliue and without
nuclei. Copious hemorrhage has taken place into these areas
and at the margin of intact tissue polynuclear leucocytes an;
numerous. I'^ibrin is abundant in the necrotic interlobular
tissue. Where widespread destruction has not occurred there
has lieen active proliferation of interstitial tissue replacing
in part destroyed parenehyina and containing numerous red
blood corpuscles and polynuclear leucocytes. The remaining
acini are often separated by newly-formed interstitial tissue
and there is the appearance of advanced chronic inhamnia-
tion. In the splenic part of the gland foci of necrosis with
hemorrhage occur and in small scattered areas there is newly-
formed connective tissue.

Experiinenl 2. — After opening the duodenum o cc. of biK^
obtained from a second dog was injected into the pancreatic
duct. Death followed within twenty hours. The peritoneal
cavity contains several cubic centimetres of bloody Muid anil
the peritoneal surface has an irregularly distributed, deep
red injection. The entire omentum is studded with con-
spicuous oi)aque white areas of fat necrosis, usually round, 1
to 1.5 mm. in diameter, and surrounded by a zone of injec-
tion. They are most abundant in the neighborhood of the
s])leen, where superlicially and on section they occupy about
one-half the exposed surface. In the mesentery of the duo-
denum near the pancreas they are numerous, but in the re-
mainder of the mesentery of both large and small intestine
they are sparcely scattered. Similar foci are present in the
retroperitoneal fat and in the properitoneal fat below the
diaphragTii. The splenic arm and the upper half of the at-
tached duodenal part of the pancreas are swollen and osdema-
tous in appearance and the lobulations are separated by tissue
iidiltrated with blood. The cut surface has a mottled dull
red and gray color, the interstitial tissue being hemorrhagic,
wjiile minute heaiorrhages wrv. in places seen within the lobu-
lar substance. The left lung is the seat of a mucopurulent
bronchitis. A culture made from the peritoneal cavity re-
mained sterile. A short bacillus was grown from the pan-
creas. Microscopical examination shows that the dull red
areas of the ])ancreas represent foci of necrosis where the
parenchyinMti}Us cells stain only with eosin and no Imigi'i
contain nuclei. The blood-vessels hero are widely dilated
and abundant hemorrhage has frequently taken place. Poly-
nuclear leucocytes are present but are not very numerous.
Such an area of necrosis and hemorrhage is at times limited
to the central part of a lobule group, while the acini furtbei-
U-inn the central duct are intact. The interstitial tissue
particularly of tlie duodenal part of the ghiud has an (edema-
tous appearance and contains red blood corpuscles, polynu-
clear leucocytes and fibrin.

Experimenl J/. — iiy means of a sliai-p pointed needle 3 ec.

of bile was withdiawu from the gall bladder and injected
into the larger pancreatic duct. The animal was killed at
the end of seven days. Upon the surface of the pancreas
where it is in contact with the duodenum are a few sparcely
scattered opaque white areas of small size. In the omentum
near tlie gland are a few suuilar foci of necrosis. The pan-
creas is normal in consistence aiitl no change is noted macro-
sco2jicall3^ Microscopic examination sliows the interstitial
tissue of the splenic and duodeual parts of the gland mod-
eiately iufiltrateil in iilaces with blood corpuscles, while here
and there it is distended and has an oedematous appearance.
The pareneliyma is normal in tlm sections examined.

ExiJCiiinenL 5. — The operation previously described was
repeated and 2.5 cc. of bile was withdrawn from the gall
bladder and after opening the duodenum injected into the
larger pancreatic duct. The dog was killed at the end of
four days. The pancreas which is not adlierent to the adja-
cent structures is hrm in consistence and has throughout a
reddish-gray color, but is nowhere hemorrhagic. (Ju the
surface of the duodenal part in contact witii the duodenum
are sparcely scattered opaque white areas of fat necrosis.
Microscopic examination of a section from thi- duodenal part
of the gland shows that newly-formed celhdar eonnecti\e
tissue has in a small area replaced the glandular elements.
I'roliferation of cells has occurred in the adjacent interlobular
tissue which contains in abundance red" blood corpuscles, poly-
nuclear leucocytes and fibrin.

Should bile enter the pancreas after occlusion of the distal
end of the diverticulum of Vater, its only opportunity for
escape would be by way of the lesser pancreatic duct. In
order to reproduce this condition, in the following experi-
ments the duodenum \vas not opened, but the duet was
exposed wdiere it approaches the intestine, ligated close to
the' duodenum and partially cut across. JJy means of a
syringe with a blunt nozzle, bile was injected into the distal
end of the duct which was then ligated.

Experimenl 6. — Into the larger duct was injected 5 cc. of
bile obtained by puncture from the dog's gall bladder. The
animal died twenty-four hours later. The peritoneal cavity
contains no excess of tluid. Opaque white areas of fat ne-
crosis are numerous upon the surface of the duodenal part
of the pancreas and in the immediately adjacent fat of the
duodenal mesentery. Similar foci are present in both layers
of the )nesentery near the stomach and pancreas and in the
fat in contact with the splenic part of the gland. The inter-
stitial tissue of the duodenal part over an area near the orifice
of the larger duct, 2.5 cm. in width, shows deep red hemor-
rhagic infiltration. The parenchyma throughout the gland
is mottled, .small dull red areas alternating with more normal
gray yellow gland substance. This hemorrhagic appearance
of the parenchyma is most marked in the duodenal part of
the gland wdicre there are homogeneous dull red areas of
considerable extent. Both lungs contain extensive deep red
areas which are feirly firm in consistence and exude very
abundant frothy serum. Microscopic examination of all parts

188

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

of the pancreas shows the presence of numerous foci of ne-
crosis. The ghind cells have assumed a hyaline appearance
and have lost their nuclei. The blood vessels in these areas
are widely distended and at times there is abundant extravasa-
tion of red blood corpuscles. Polynuclear leucocytes in mod-
erate number are seen between the necrotic cells. The inter-
lobular tissue is in many places much distended, containing
red blood corpuscles, poljmuclear leucocytes and fibrin.

Experiment 7.- — The operation already described was re-
peated and 3.7 cc. of bile obtained from the gall bladder of
the same dog was injected into the larger duct. The animal
was killed three days later. Upon the surface of that part
of the pancreas which is in contact with the duodenum and
in the fat immediately adjacent to the splenic part are a few
opaque areas of necrosis. Tlie pancreas is very firm through-
out. On section the glandular lobules are found to be sepa-
rated by septa of interstitial tissue which are firmer and
thicker than usual and near the termination of the larger
duct infiltrated with blood. In the duodenal and splenic
parts of the gland microscopic examination demonstrates
within the lobular tissue numerous small areas where newly-
formed, very cellular interstitial tissue replaces groups of
acini. The interlobular tissue is infiltrated with red blood
corpuscles and often contains in great abundance polynuclear
leucocytes and fibrin.

SYNOPSIS OF EXPERIMENTS.

I. — Duodenum Opened and Duct Injected.

Amount Mode
of bile. of death.

Pancreas.

No. 1. . . .5tc.

No. 3 5cc.

No. 4 Src.

Killed in Hemorrhagic iuflamma-

7 days. tion and sclerosis.

Killed in Hemorrhagic inflamma-

5 days. tion and sclerosis.

Died in Hemorrhagic inllamma-

30 hours. tion.

Killed in Slight hemorrhagic

Fat.

Eat necrosis
near pancreas.

Fat necrosis.

Extensive

fat necrosis.

Slight

fat necrosis.

J, > o t;.. Killed in Slight hemorrhagic in- Slight
"■'' ■ 4 days. tiltration and sclerosis. fat necrosis.

No. 6.

. 5fc.

II. — Duct Opened, Injected and Ligated.
Died in Hemorrhagic iullamma-

24 hours.

tion.

^Fat necrosis.
Slight

„ r. o 7,. Killed in Hemorrhagic intlamma-

■ ' "' 3 days. tion and sclerosis. fat necrosis.

The injection of 5 cc. of bile into the pancreatic duct caused
hemorrhagic inflammation of the gland in four dogs, two of
which died within twenty-four hours after the operation.
Death did not follow the use of smaller amounts and the
changes produced in the organ were less wide spread and
severe. In every case necrosis of the adjacent fat accom-
panied the lesion of the pancreas, and in the two instances in
which death occurred spontaneously foci of necrosis were
abundant and disseminated. In Experiment No. 1, though
the entire splenic arm of the gland was the seat of an intense
inflammatory reaction, eoverslips and cultures demonstrated
the absence of bacteria. The presence of bacteria in the
pancreas of dog No. 2, which died twenty hours after the

operation, is not surprising since the injection was made
through the duodenal orifice of the duct.

Microscopic examination confirmed the diagnosis of hemor-
rhagic pancreatitis and demonstrated the identity of the ex-
perimental lesions with that which occurs in human cases.
The injected bile first causes necrosis of the parenchymatous
cells with which it comes into contact. They loose their
nuclei and their protoplasm assumes a homogeneous hyaline
appearance and stains deeply with eosin. The injurious
action of the irritant upon the blood-vessels is manifested by
the occurrence of hemorrhage into these necrotic areas. An
inflammatory reaction now ensues and is characterized by the
accumulation of polynuclear leucocytes and fibrin in the in-
terstitial tissue and in the necrotic parenchyma. Tlie ne-
crotic material undergoes disintegration and a rapid new
growth of interstitial fibrous tissue in part or wholly replaces
it. Where death docs not rapidly follow the primary effects
of the operation opportunity is given for the occurrence of
secondary changes in the gland. The experimental lesion is
not in all cases so extensive as that recorded in the accom-
panying autopsy report. In these experiments a single injecy
tion of bile is made, while in the human case bile is repeatedly
poured into the organ.

Conclusions.

(1) A small gall stone impacted in the diverticulum of
Vater may occlude the common orifice of the bile duct and
duct of Wirsung and convert tliem into a continuous closed
channel. Bile enters the pancreas by way of tlie pancreatic
duct and the pancreas becomes the seat of inflammatory
changes characterized by necrosis of the parenchymatous
cells, hemorrhage and the accumulation of inflammatory
products. Anatomical peculiarities of the diverticulum of
Vater do not permit this sequence of events in all individ-
uals.

(2) Injection of bile into the pancreatic duct of dogs causes
a necrotizing hemorrhagic inflammation of the pancreas re-
sembling tlie human lesion, and like it accompanied by fat
necrosis. Necrosis of the parenchymatous cells and hemor-
rhage represent the primary action of the bile; an inflamma-
tory reaction rapidly follows.

(3) The frequent association of cholelithiasis with hemor-
rhagic and gangrenous pancreatitis is the result of impaction
of gall stones at the orifice of the diverticulum of Vater and
penetration of bile into the pancreas.

THE JOHX W. GARRETT IIVTERNATIOlVAIi
FELI.O\VSHIP.

It is gratifying to be able to announce tliat the John W.
Garrett International Fellowship has been founded by Wil-
liam Johnston in connection with University College, Liver-
pool, in memory of the late John W. Garrett, of Baltimore,
and former Trustee of this Hospital, with the title of the
" John W. Garrett International Fellowship in Pathology and
Physiology."

Apeil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

189

The Fellowship is to he open to members of Universities
and Medical Schools in the United States, without, however,
jirecluding the conferring of the Fellowship upon members
of other foreign schools.

The Fellow is to be elected by the Faculty of University
College, Liverpool, on the nomination of the Professors of
Pathology and Physiology. He is elected for one year, but
may be reappointed. He is required to devote himself to
research in physiology or pathology and bacteriology, under
the direction of the Professors of Physiology and Pathology.
The work is to be done in the Thompson Yates Laboratories
of University College, but by special permission from the
Faculty the Fellow may pursue necessary investigations else-
where. The expenses of all researches are to be met out of
the funds of the laboratory.

NOTES ON NEW BOOKS.

LLhrbuch der Aiiatomie der Hau.stiere mil besoudei-ei- BLiiUk-
sicUtigung' des Pferdes. An Stelle des in 1. und 3. von
Leyh, in 3. und 4. von Franck, in 5. Auflage von Martin
Herausgegebenen Handbuclis der Anatomic der Ilaustiere.
VolLstiindig neu Bearbeitet. Von Dr. Paul Martin, pro-
fessor an der Tierarzneisetmle in Ziiricli. (StutUjurt: Yerlag
von Scluckhardt cG EUiicr (Koiinid Wiltircr), 1901.) Price 40
Afarks.

It is a ijleasnre for those interested in tliis subject to go
through the new edition of tlie Lejli-Franclc Anatomy, thor-
oughly revised, in fact rewritten, by Professor Martin. The
scope of the work is so extensive and the treatment so compact,
thorough and scientific that students of veterinary medicine
(or any medical students) must rise far above the average in
ability and in training to pursue this anatomy.

The work is divided into two large volumes, the first of which
is devoted to general anatomy and embryology to the extent
they underlie the systems of the body. Tlien the histology and
microscopic anatomy of the organs follow. This arrangement
of the general part makes it possible to consider phylogeny
with ontogeny without causing confusion. In fact this is
necessary. By this arrangement the first volume serves as a
broad scientific basis for the second, thus giving a firm founda-
tion upon which the systematic anatomy is easily united with
the other morphological sciences.

The author includes with the discussion of the organs their
histology and microscopic anatomy, for his experience as a
teacher is that such treatment has always been welcomed by
his students. In this direction the text is extensive enough and
the illustrations sufficiently numerous to serve as a good foun-
dation for these subdivisions of the main subjects.

The second volume is devoted to descriptive systematic auat-
omy. It is arranged to guide the student in the study of
dissections.

All in all the work reminds one somewhat of Qnain's Anatomy,
or rather of Kauber's revision of it. The illustrations are num-
erous and excellent, the text is well written and clear, showing
that the author is master of the svibject.

That an Anatomy of this rank is in its si.xfh edition speaks
much for veterinary education in Europe. Students with a
training in anatomy sufficiently broad to grasp this work are
raised far above the average veterinarian of America. Fortu-
nately, we have two or three veterinary colleges in which the
course in anatomy is up to the level of Martin, and wc cordially

recommend this book to them as well as to all others who are
interested in the comparative anatomy of the domestic animals.

K Text-Book of Histology. By .\. A. Bohm and N. vo.\ Davidoff.
Edited by G. Carl Huuer; translated by 11. 11. C'lsniNG.
(Phihidilithia: W. B. Saunders & Co., WOO.)

It is a matter for congratulation that so good a Ijook as
Bohm and von Uavidoff's Histology has been translated into
English, and put within the reach of all American students of
anatomy. It would seem at first sight that a book of this char-
acter written in German could be as easily and widely used as
an English edition; but such is by no means the case. To the
a\erage student a foreigii language forms a very considerable
obstacle, and a good book written in German, for example, is
not infrequently put aside for a less valuable English substitute.
In editing- an English version of what is one of the best short
Histologies in any language. Dr. Huber has rendered a valuable-
service to both teachers and students; and in bringing this book
to a certain extent up to date, he has made it a most valuable
laboratory guide.

It is .somewhat to be regretted that the editor did not in this
work bring all the parts of the book equally in touch with the
latest literature. Many of the descriptions seem to have been
left as they were in the original, no regard being given to work
which has been done since that edition was published. Some
organs, on the other hand, are described in great detail, and
fairly full references made to the original sources of informa-
tion. An excellent account is given of the epithelial and con-
nective tissues, and the addition of Dr. Huber's own work to
the section on nervous tissues makes it an interesting and
valuable article. The chapters on muscle and blood, however,
might with advantage be much amplified. The lymx>h and thy-
roid glands also merit more attention than they receive. Very
good descriptions are given of all the thoracic and abdominal
viscera, especial attention being given in almost every case to
the nerve supply. This influence of Huber's own work is felt in
many of the chapters, and the detailed description of nerve
endings in the various organs Is a conspicuous feature of this
edition of the book. The blood supply in most cases is much
less fully described.

The illustrations are excellent throughout, and good judgment
is shown in their selection. There are very few that could be
omitted with advantage. Perhaps the same criticism, however,
could be made of the figures as has been suggested concerning
the text. Some chapters are excellently illustrated and others
only indifferently so. This is hardly to be avoided in treating
so large a subject in such a brief si^ace.

The part which deals with special technique is one of the
most valuable in the book. It is compiled with the greatest
care and contains numerous methods which will be of very real
assistance to laboratory workers. The methods of maceration
and digestion of tissues will be found especially instructive in
laboratory courses.

A good index and a list of the articles referred to in the text
complete this excellent book, upon the appearance of which
Dr. Huber is to be sincerely congratulated. It is without doubt
one of the best brief text-books of Histology to be obtained at
l^resent.

J. B. MacCallum.

Hand Atlas of Human Anatomy. By Werner Spalteholz, Ex-
ti-aordinary Professor of Anatomy in the University and
Custodian of the Anatomical Museum at Leipzig, with the
advice of Wiluklm His, Professor of Anatomy in the Univer-
sity of Leipzig. Translated from the third German edition
by Lewellys F. Barker, Professor of Anatomy in tin-
University of Chicago, with a preface by Franklin P. Mall,

190

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

rniCc-.ssoi- of Anatomy iu the Johns Hopkins University at
Ualtiiuore. Vol. I, Bones, Joints, Ligaments. Cloth, $3.50.
Pages 335, iigures 1-380. {LdpzUj: S. Jlirxcl; New Ydi!;: (1.
Stechert.)

Descril)ti\e anatomy is essentially a study of fcirni and of
spaeial relalions. Pictnires and models constitute the most
satisfactory means of exiiressing' these i>heuomena. Illustra-
tion is therefore a most important factor in anatomical study.
Pictures sho\\'ing the main anatomical conditions which the
researches of centuries have revealed serve as the best guide
in dissection; pictorial illustration is the best means of record-
ing the work of this kind. The student should have good
pictures to aid liim in his ta.sk. lie should sketch the results
of his dissections in order to formulate clearly the ideas revealed
to him by the work.

Anatomical illustration is an interesting subject. Before the
beginning of the nineteenth century it was the habit of the
anatomist to make a i-ough sketch of a dissected jjart. This
sketch was then turned over to the engraver, who elaborated
the drawing on wood or copi)er, elinunated its crudities and
l)roduced. a fine jiicture. The effect of the engraver's imagina-
tion is most clearly seen perhaps iu the plates that aceonai)any
the work of Versalius and the earlier anatomists. The evis-
cei'ated .subject of the dissection may there often be seen smil-
ing in the midst of a beautiful landscape. As a rule, ]>arts of
the body are shown out of their true positions in the body,
often considerably distorted, in order to show tlie front and
back of the same object in the same picture.

Ill tile early part of this century the lithograph was iiitro-
iliieetl as means of illustration. Here too the hand of the
lithographer could be relied upon to correct and ehilniratc
original sketches. Many of the plates nuide by this process
are very beautiful, though here, as iu the case of the engrav-
ing, there has always been the danger of error owing to the
elal)oration being made from the drawing, not from the object.

or i-ccciit \ears the attemj)t has been made more and niori
to |)ieture the various parts of the body in their true positions
relative to the body contour, to picture the deeper muscles, foi-
instance, as they appiar when the sujierficial muscles have been
removed, to show nerves and arteries liy re|)resentiiig parts
covering them as cut away instead of pulled aside. Tliis liius
necessitated much more care in the preiiaration of the |>ai'ts to
be pictu/ed; it has necessitated much more skill on the pail
of the artist who attempts to depict the parts in their true
relations and proportions. Unless the anatomist is an artist of
unusual skill and ability he must call in the services of a
trained artist if he wishes to illustrate his worl< well.

This necessity is rendered still more imperative by the modern
methods of making plates by the aid of jjliotograpliy. The
anatomist cannot hand over a rude sketch to the publisher who
desires that the cheaper photograph methods of reproduction
be used. The crudities of the sketch appear in the reproduc-
tion with startling distinctness. The reproduction appears less
well finished instead of better finished than the original. The
trained artist who can make drawings that can stand mechani-
cal reproduction has become a necessity. In many ways tliis
is a great gain. It is far better that the elaboration should be
nuide from the object itself, as is the case when an artist is
employed, rather than from a sketch, as was the case in the
old days of engravings.

tiood pictures, moreover, are seldom possible without the aid
of a constructive imagination. Anatomical ijictnres reproduci'd
from jihotographs of dissections are with few exception,s bar-
baric in their crudity. I'hotography alone can be depended upon
only when the object jiictiired is extremely simple or when the
very greatest care is taken iu making the dissection and the

photograph is afterwards carefully retouched. Riidingcr's beau-
tiful Nerve Atlas shows with what success this may be done.

In the Atlas before us modern conventional methods of illus-
tration have been used, but they have been used with a perfec-
tion not hitherto seen in text-books of human anatomy. The
drawings have been made by skilled artists and for the most
part from careful dissections especially made for the purpose.
Wash-drawings re])roduced in half-tone are used to illustrate
detailed structures and oxitline drawings are freely used for the
purpose of pointing out relations. In illustrating the ligaments
the bones are toned yellow for contrast. Colors are also used
with effect in the volume on the muscles and blood-vessels which
has appeared in (ierman but has not yet been translated into
English.

Spalteholz is well aecpiainted not only with the literature of
anatomy but also with practical dissecting. His experience has
led him to choose points of view both striking and instructive.
Throughout, the attempt has been made to show things in their
true relations.

In the volume ))cfore ns (Vol. I, Bones, Li^ainenfs and .joints)
there is a preface by I'rof. Mall in which the value ol' pictures
to the student of anatomy is emphasized, and one Ijy the author
in \\hich the general scope of the work is set forth. We could
wish that Spalteholz had authorized the translation of his very
excellent preface to the German edition. The English of the
preface prepared for the ti'anslation is far from idiomatic.

The points illustrated in the various pictures are designated
by ])rinting their Latin title in full at the margin of each figure.

The bones of the skull are first dei:)ieted, several views of each
bone being' given in order that all the main points may be illus-
trated. The method of showing the relations of several of the
bones is particularly hapi)y. An individual bone, for instance
the ethmoid, is drawn carefully in detail. The neighboring
bones are drawn in .simple outline. Following the illustrations
of the individual bones several fine pictures are given of the
skull as a whole, and of the chief cavities of the skull; the
vertebral and ribs and the bones of the limbs are then taken up
in detail. A very good ])ictnre of the .skeleton of the thorax is
given. On outline drawings muscle attachments are indicated.
The section on the ligaments is very satisfactory and is much
moj-e extensive than is common in the text-books. The iutrriial
architecture of the bones is shown in several special drawings.

JVomenclature is another mo.st ira])ortant consideration in the
study of anatomy. The great wealth of detail which four cen-
turies of earnest work has brought to light concerning the
structure of the human body has been accompanied by an even
greater mass of names. Investigators who have found nothing
new or will) haw reiliseo\ered facts alrea(-l.>' known lia\'i' not
hesitated to eniii new terms until descriptive aiuitomy fairly
groans iiuder the load of ternil oology which rests on its should-
ers. A great advance was made by the Anatomissche Gesell-
schaft at their meeting in Basel in IS'JS, when they adopted a
list of dcscri])tive terms which tend greatly to simplify the
subject (His; Siipplementband zur Anat. Abtheilung des Archiv
f. Anatomic u. Physiologic, ]S<)5).

The "New Nomenclature" has been used svsleniatieally
throughout the book with a few unimportant exceptions. We be-
lieve that it is a mistake, however, to give a Latin name to every
nook and enriu'r of the hiiniaii body. The more detinite struc-
tures of the human body, like the bones, the main muscles, the
larger arteries, veins and nerves and similar structures, are best
designated by a specific name. Most of these tenn.s have been
derived from the Latin and by usage havfe become embodied in
the various modern languages, sometimes unchanged, some-
times with slight alteration. Thus clavicle, humerus, femur,
biceps, are all words in more or less common use in English.
We think it is a very grave mistake, a relic of unprogressive
scholasticism, to make use of Latin wheu terms are used to

Apkil-May-June, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

191

describe as well as designate various definite sti'uetures of this
nature. In the desci-iption of the frontal bone we can see no
possible advantage in an English book in writing " Tu the medial
l)art of the margo supraorbit. there is often a shallow notch,
innsma fioiitalis (rarely a foramen fnmtalc) (for the a. frontalis;
r. frontal, n. frontal.) and lateralward from this a foraiiicit
siipruorhiUile or an iiicUuru sujn'aorbitalis (for the a. supraorbit.;
n. supraorbit.) the anterior convex surface, faciei froiitalw " — etc.
This gnat mass of descriptive Latin terminology merely serves
to confuse the student and to take his mind from the essential
to the unessential, from the object to the descriptive term.
.\n aljsurd amount of detailed acquaintance with dissociatetl
parts of the body is at jiresent demanded of the medical student.
It is a pity to continue to add a mass of Latin to his burden at
the very time that he is beginning to be freed from the shackles
of therapeutical botany and its barbarisms.

The main object of an anatomical atlas is to furnish good,
clear pictures of the various parts of the body. The text is of
minor importance and its chief function is to point out the
relations revealed by the pictures and the relations of the
l)ictures to one another. This function is admiralily scned l)y
the text accompanying the illu.strations in Spalteholz's atlas.
Such a text confessedly does not take the place of a good text-
liiiok. In addition to the atlas the student needs a book in
uhieli tlie dry subject of descriptive anatomy is brightened and
enriched by treating of the various parts of the body in their
rehition to physiological phenomena, to embryology and to
conii)arative anatomy. Gegenbaner's Anatomic des Menschen is
an admirable exn tuple of such a text-book in which the side of
f'lnbryology and comparative anatomy is especially emphasized.

The English reading student of medicine is fortunate in hav-
ing had translated for his use this excellent Atlas of S])aIteholz.
He is esi)ecially fortunate in having a translation that has been
nuide by a man of the marked ability of Professor Barker.
Professor Barker has been very true to the original text and yet
lias been able to give us a text exceptionally smooth for a trans-
lation .so literal.

The printing of the book shows the care and nicety thai
distinguishes the firm of Ilirzel.

We could wish that there were more pictures in this volurne
in which the skeleton as an organic whole were shown. For
instance, not only is there no picture of tlu' skeleton as a whole,
but there are none of the limbs as a wliole. It is not enough,
we think, to give in an atlas merely the hand, the forearm and
the humerus as separate parts.

In comparing' the illusti'ations of this Atlas with text-books
of a similar scojae we fiud that that of Toldt is the one most
similar to it in scope. The beautifully illustrated text-books of
Sappey and of Testut are much more exi)ensive and have a
iliiYerent function to perform. Coinpared with Toldt's Atlas we
llud the pictures in Spalteholz are more delicate in detail and
less diagrammatic. On the other hand, the i)ictures in Toldl
are made sharp and vigorous, owing to the dcijendence on lines
rather than on light and shade. Toldt also has done well in
showing the organs in relation to larger areas of the body.
The superiority of the pictures in Spalteholz lies in their natural
tone.

Charles Uussell Bakdeen.

BOOKS KECEIVEU.

.1 I'nwiical 'J'rcali-ie uii Uulcria Mcdica and 'I'livrdiicKlirs With
Especial Keference to the Clinical Application of Drugs.
By John V. Shoemaker, M. D., LL. I). Fifth edition, thor-
oughly revised. (Students' Edition.) 1900. Svo. 766 pages.
F. A. Davis Company, Philadelphia, New York, Chicago.

Mcdiral and Sitriiicul Reimits of the Boston City Hosiiital. Eleventh
Series. Edited by Herbert L. Burrell, M. D.. W. T. Coun-
cilman, M. D., and Charles F, Withiugton, M, D. 1000. Svo.
254 pages. Published l)y the Trustees, Boston,

Aiiiiiicdn Tcd-t-Iiook of 1'hys'wloiiy. Edited by William 11. Unwell,
I'll. 1)., M. D. Second edition, revised. Volume II. I'.ilil.
-Ito. 553 pages. W. 1!. Saunders and Company, I'liiladcl-
phia and London.

Alistrart of Ilt'iioit on ttif Orii/iii and Hiyniid of 'I'liiittoid Fcitr in
r. N. Militiiri/ Ciiiiiji.s Dnriii;/ thr Xiiiiiiixli War af ls:iS. I'.y
Waller r.ecd, M. D., Victor C, Vaughan, M. D,, anil JCclwaril
t). Shakespeare, M, D. 1900, Svo, 239 pages. Government
Printing Office, Washington,

.s7((/i: of New York. Stale Coniniission in Lunacy. Eleventh An-
nual Keporl, October 1, 189S, to September 30, 1S99. Two
volumes. Svo. 1900. Albany.

.1 Tcit-Bool; of rallioloyy. By Alfred Stengel, M. D. Third cili-

tion, revised. With 372 illustrations. 1900. Svo. S73

pages. W. B. Saunders and Company, Philadelphia and
London.

Uimnfevtiiin and Disinfcdaid-s. A Treatise upon the Best Known
Disinfectants, tlieir I'se in the Destruction of Disease
(Jernis. with .Special Instruction for their ApiJlication in
the ( oMiinouly Kecognized Infections and Contagious Dis-
eases. By II. M. Bracken, M. D. 1900. ItJmo. 91 pages.
Published by the Trade Periodical Comfiany, Chicago.

Di.stain's of till lliiirl: ttiiir Itiiiiinosis and Tniilininl. Wv .\lbert
Abranis, A. M., M. D. (lleitlelberg), F. It. M. S. 1900. ]2nu).
170 pages. (J. P. Engelhard and Company, Chicago.

I_'riiiiiry Diuiinosis mid Tivutinvnt. By John W. Waiuwright,
M.D. 1900. IL'nio. 13S pages. (J. P. Engelhard and Com-
[lany, Chicago.

Trunsuvtions of llic Conijn:s.i of Anterii-iin I'liy>,-irian>i and (Vh/v/c/h.s-.
Fifth Triennial Session held at Washington, D. C, May first
and second, 1900. Svo. xlix + 119 pages. Publishi'd l)y the
Congress, New Haven, Conn.

liini/irorni in the hiijhl of lleirnt Ifesearvlt. Patholiig'> — Treatment
— Prophylaxis. By Malcolm Morris. With twenty-two
micro-phot ograjdis and one coloured plate. 189S. Svo. ]-t2
pages. Cassell and Comiianx, Limited. London, Paris and
Melbourne.

Tlie Siiriiinil 'I'll iilniiiit of Cirnyi nilul iiinl I'lilliotiuiical llis/iiiiirc-
niinls of the Fare. Abstract of the Miitter Lectures of the
College of Physicians of Philadelphia for 1900. By John
B. Boberts, A.M., M.D. Svo. 53 images. 1900. The Phila-
delphia Medical Publishing Comiiany, Philadelphia.

Tliirti/-/ir.st AniiiKil h'cjiort of tin: Slate Board of Health of A/«,s-«((-
eliiixell-i: 190(1. Svo. Ivii + SP: pages. Wright and Potter
Printing Co., Boston,

'rrinisaelions itf the Anieriean Urthofedie Association. Fourteenth
session held at Washington, D, C„ May 1, 3 and 3, 1900,
\'olunie XIII, Svo. xxviii + 340 pages. 1900. Published
l>y the .\ssoi'iati(m. Philadelphia.

'rriiiisiirtionx iif till- Ainiririin (lyneeoloijieul Soeielil. N'olnmc 25.
l''oi- the year 1900. Svo. xlvii + -154 pages. Philadelphia.

'I'lie 'Vale of u Field Uusinlul. By Frederick Treves. With four-
teen illustrations from <)riginal photographs. 1900. 12nio.
109 pages. Cassell and Company, Limited. London, Paris,
New York and Melbourne.

.1 Guide to the In.itruments and Ap/diances Required in Varioim
OjiirationK. By A. W. Mayo Bobson, F. K. C. S. Second
Edition. 1900, 21. 63 images. Cassell and Coni|iany, Tiim-
ited. Lomloii, I'aris, New York and Melbourne.

192

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-122-123.

Tropical Diseases. A Manual of the Diseases of Warm Cli-
mates. By Tatrick Manson, C. M. G., M. D., LL. D. (Aberil.)
Kevisecl and enlarged edition. With 114 illustrations and
two coloured plates. 1900. 13mo. xx + 084 pages. CasscU
and Company, Limited. London, Paris, New York and
Melbourne.

Diseases of the Tongue. By Henry T. Butlin, F. E. C. S., D. C. L.,
and Walter G. Spencer, M. S., M. B. (Lond.), F. E. C. S.
Illu-strated with eight chromo-lithographs and thirty-six
engravings. 1900. Svo. xii + 475 pages. Cassell and Com-
pany, Limited. London, Paris, New York and Melbourne.

Report of the Sunieon-Generul of the Army to the Secretary of War.
For the Fiscal Year ended June 30, 1900. 8vo. 411 pages.
1900. Government Printing Office, Washington.

Operative and Practieal Surgery: For the Use of Students and
Practitioners. By Thomas Carwardine, M. S. (Lond.),
F. E. C. S. With 550 illustrations, most of which are original
drawings by the author. 1900. 8vo. xx -j- 661 pages. John
Wright and Company, Bristol.

The American Tear-Book of Medicine and Surgery. Collected and
arranged with critical editorial comments by S. W. Abbott,
M. D., A. Church, M. D., et al. Under the general editorial
charge of George M. Gould, M. D. Two volumes. 1901. Svo.
W. B. Saunders and Company, Philadelphia and London.

Golden Rules of Skin Pracficf. By David Walsh, M. D. Edin.
[1900] 32mo. 102 pages. " Golden Eules " Series. No. viii.
John Wright and Company, Bristol. Simpliin, Marshall.
Hamilton, Kent & Co., Limited, London.

Transactions of the Clinical Society of London. Volume the
Thirty-third. 1900. Svo. xlix + 272 pages. Longmans,
Green and Company, London.

A Text-Book of Histology, Including Microscopic Tcchnic. By A. A.
Bohni, M. D., and M. von Davidoff, M. D. Edited, with Ex-
tensive Additions to both Text and Illustrations by G. Carl
Huber, M. D. Authorized translation from the second re-
vised German edition by Herbert H. Gushing, M. D. 1900.
Svo. 501 pages. W. B. Saunders and Companj% Philadel-
phia.

Introduction to the Study of Medicine. By G. H. Eoger. Author-
ized translation by M. S. Gabriel, M. D. With Additions by
the Author. 1001. Svo. 545 pages. D. Appleton and Com-
pany, New York.

Panama and the Sierras, A Doctor's ^yundvr Days. By G. Frank
Lydston, M. D. Illustrated from the Author's Original
Photographs. 1900. 12mo. 283 pages. The Eiverton Press,
Chicago.

Hypnotism. A Complete System of Method, Application and
Use, Prepared for the Self-Instruction of the Medical Pro-
fession. By L. W. De Laurence. Illustrated. 1901. 12mo.
256 pages. The Henneberry Company, Chicago.

A Tcit-Book of Diseases of the Nose and Throat. By D. Braden
Kj'le, M. D. With 175 illustrations, 23 of them in colors.
Second Edition. 1900. Svo. 646 pages. W. B. Saunders
and Company, Philadelphia.

The Treiitmcnt of Fractures. By Charles Locke Scutklcr, M. D.,
Assisted by Frederic J. Cotton, M. D. Second edition, re-
vised. With 611 illustrations. 1901. Svo. 457 pages. W.
B. Saunders and Company, Philadelphia and London.

Transactions of the College of Physicians of Philadelphia. Third
Series. Volume the Twenty-second. 1900. Svo. Ivi -)- 282
pages. Printed for the College, Philadelpliia.

The Practice of Medicine. A Text-Book for Practitioners and
Students, with Special Reference to Diagnosis and Treat-
ment. By James Tyson, M. D. Second edition, thoroughly
revised and in parts rewritten. With 127 illustrations, in-

cluding colored plates. 1900. Svo. 1322 i)ages. P. Blak-
iston's Son and Co., Philadelphia.

A Tcj-J-Book of Prarlivdl Ohshirics. By Egbert II. (.;r;iiiclin, M. D.,
with the eollaboralion of George W. Jarnian, M. I). Third
edition, revised and enhirged. Illustrated with fifty-two
fLill-pnge photograpliic plates and one hundred and five
illustrations in the text. 1900. Svo. 511 pages. F. A.
Davis Company, Philadelphia, New York, Chicago.

Ohsletric and Gynecologic Nursing. By Edward P. Davis, A. M.,
M. D. Illustrated. 1901. 12mo. 402 pages. W. B. Saun-
ders and Company, Philadelphia and London.

A Medico-Legal Manual. By William W. Keysor. 1901. 12mo.
316 pages. Omaha.

A Pilgrimage: or the Sunshine and Shadows of the Physician. By
William Lane Lowder, B. S., M. D. 1897. 24mo, vi -|- 190
pages. Louisville, Kentucky.

Report Relating to the Registration of Births, Marriages and
Deaths in the Province of Ontario for the year ending 31st De-
cember, 1S99. Printed by order of the Legislative Assembly
of Ontario. Svo. 1901. 49 -|- ccxlii pages. L. K. Cameron,
Toronto.

JoUl) Questions on Medical Subjects Arranged for Self-Examination.
With the proper references to standard works in which
the correct replies will be found. Third edition, enlarged.
1901. 32mo. 230 pages. P. Blakiston's Son and Company,
Philadelphia.

Human PlaccntatioH. An Account of the Changes in the Uterine
Mucosa and in the Attached Fetal Structures During Preg-
nancy. By J. Clarence Webster, B. A., M. D. (Edin.),
F. R. C. P. E., F. E. S. E. With 233 illustrations. 1901. 4to.
126 pages. W. T. Keener and Company, Chicago.

A Text-Book of Gynecology. Edited by Charles A. L. Reed, A. M.,
M. D. Illustrated by R. J. Hopkins. 1901. Svo. xxv -f- 900
pages. D. Appleton and Company, New York.

Nursing Ethics: For Hospital and Private Use. By Isabel Hamp-
ton Robb. 1001. 12mo. 273 pages. J. H. Savage, Cleve-
land.

The Medical Annual: A Year-Book of Treatment and Practi-
tioner's Index. Nineteenth Year, 1901. 12mo. Ixxx -{- S47
pages. John Wright & Co., Bristol. Simpkin, Marshall,
Hamilton, Kent & Co., Ld., London.

Anatomical Atlas of Obstetrics with Special Reference to Dia(inosis
and Trcaiment. By Dr. Oskar Schaeffer. Authorized trans-
lation from the second revised German edition. Edited by
J. Clifton Edgar, A. M., M. D. With 132 Figures on 56 Litho-
graphic Plates, and 38 other Illustrations. (Saunders'
Medical Hand-Atlases.) 1901. 13mo. 315 pages. W. B.
Saunders & Company, Philadelphia and London.

Atlas of the Nervous System, Including an EpUome of the Anatomy,
Pathology, and Treatment. By Dr. Christfried Jakob. With
a preface by Prof. Dr. Ad. v. Striimpell. Authorized trans-
lation from the second revised German edition. Edited by
Edward D. Fisher, M. D. With 112 Colored Lithographic
Figures and 139 other Illustrations, many of them in Colors.
(Saunders' Medical Hand-Atlases.) 1901. 12mo. 21S i>ages.
W. B. Saunders and Company, Philadelphia and London.

rtcrine Fibromyotnata. Their Pathology, Diagnosis, and Treat-
ment. By E. Stanmore Bishop, F. R. C. S., Eng. With 49
Illustrations. 1901. Svo. xii -|- 323 pages. P. Blakiston's
Son and Company, Philadelphia.

A Text-Book of the Practice of Medicine. By Dr. Hermann Eich-
horst. Authorized translation from the German. Edited
by Augustus A. Eshner, M. D. Two Volumes. 1901. Svo.
W. B. Saunders & Company, Philadelphia and London.

Al'KIL-ilAY-JrXE, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

193

THE lOHNS HOPKINS MEDICAL SCHOOL

FACULTY.

Daniel C. Gii.max, LL.D., President.

InA Ke.msen, M. D., Ph.D., LL.D.. Professor of Chemistry.

■Wir.r.iAM H. WEr.CH, M. D.. LL.D.. Professor of Pathology.

WiM.iAM 0<LER, M. D., LL.D., F. K. S., Prof essor of Medicine.

Hexkv M. HfHD, M. D., LL.D., Professor of Psychiatry.

Howard A. Kelly, M. D., Professor of Gynecology.

■WiLLi.AM K. Brooks, Ph.D., LL.D., Professor of Zoology.

William S. Halsted, SL D., Professor of .Surgery.

John .1. Abel. M. D.. Professor of Pharmacology.

William H. Howell, Ph.D., M. D., Professor of Physiology, and Doau of the

Medical Faculty'.
Franklin P. .Mall. M. D., Professor of Anatomy.
J. WriiTRiiiGF) Williams. M. D., Professor of Obstetrics.
AViLLr.\M D. liooKER, M. D., Clinical Professor of Pediatrics.
John X. Mackenzie, J[. D., Clinical Professor of Laryngology
Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology.
Henky M. Thomas, M. D., Clinical Professor of Neurology.
J. WiLLi.iMS Lord, M.D., Clinical Professor of Dermatology.
Thomas C. Gilchrist, M. B., .M. R. C. S., Clinical Professor of Dermatology.
Hfnr Y J. Berkley, M. D., Clinical Professor of Psychiatry.
William S. Thayer, M. D., Associate Professor of Medicine.
John M. T. Finney, M. D., Associate Professor of Surgery.
Hoss G. Harrison, Ph.D., Associate Professor of Anatomy.
William W. Kussell, M. D.. Associate Professor of Gynecology.
Thoji.as S. Ci'LLEN, M. B., Associate Professor of Gynecology.
Eeid Hunt, Ph.D., m!d.. Associate Professor of Pharmacology.
Robert L. R.a.ndolph. M. D., Associate in Ophthalmology and Otology.
Tho.mas B. Futcheb, M. B., Associate in Medicine.

GENERAL

Joseph C. Bloodoood, M. D., Associate in Surgery.

Charles K. Bakdeen, M. D., Associate in Anatomy.

Harvey W. Cusmxn, M. D , Associate in Surgery.

George W. Dobbin, M. D., Associate in Obstetrics.

Walter Jones. Ph.D., Associate in Physiological Chemistry and Toxic:-)logy .

Norman MacL. Harris, M. 13., Associate in Bacteriology.

William G. MacCallu-m, M. D., Associate in Pathologj-.

Frank R. Smith, M. D., Instructor in Medicine.

H. Barton Jacobs. M. D., Instructor in Medicine.

Huoh H. Young. M. D., Instructor in Genito-Urinary Diseases.

Thomas McCrae, M. B., Instructor in Medicine.

Henry McE. Knower, Ph.D., Instructor in Anatomy.

Percy M. D,iwsoN, M. D., Instructor in Physiology.

Eugene L. Opie, M. D., Instructor in Pathology.

Mervin T. Sudler, Ph.D., Instructor in Anatomy.

George Walker, M. D., Instructor in Surgery.

Stewart Paton, M. D.. Assistant in Clinical Neurology.

Harry T. Marshall, M. D., Assistant in Pathology.

Charles P. Emerson, M D., Assistant in Medicine.

Elizabeth Hurdon, M. D., Assistant in Gynecology.

Henry O. Reik, M. D., Assistant in Ophthalmology and Otology.

L. P. H.amburger, M. D.. Assistant in Medicine.

F. W. Lynch, M. D., .\ssistant in Obstetrics.

John B. MacCallu.m, M. D., Assistant in Anatomy.

Warren H. Lewis, M. D.. Assistant in .\natomy.

Joseph Erlanqer, M. D., Assistant in Physiology.

H. W. Buckler, M. D., Assistant in Obstetrics.

William S. Baeh, M. D., .\ssistant in Orthopedic Surgery.

STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an in-
tegral and coordinate part of the Johns Hopliins University, and It also derives great advantages from its close affiliation with the Johns Hopkins Hos-
pital. The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the
middle of June, with short recesses at Christmas and Easter. Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital.
While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable
preliminary education and upon thorough training in the medical sciences. The first two yt^rs of the course are devoted mainly to practical work, com-
bined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology Physiological Chemistry.
Pharmacology and Toxicology. Pathology and Bacteriology. During the last two years the student is given abundant opportunity for the personal study
of cases of disease, his time being spent largely in the Hospital AVards and Dispensary and in the Clinical Laboratories. Especially advantageous for
thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout
the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives:

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

2. Graduates of approved colleges or scientitic schools who can furnish evidence: (a) That they have acquaintance with Latin and a good reading
knowledge of French and German; (h) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given
!n these subjects in this university.

The phrase " a minor course." as here employed, means a course that requires a year for Its completion. In physics, four class-room exercises and
three hours a week In the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each
subject.

3. Those who give evidence by examination that the.v possess the general education Implied bv a degree in arts or in science from an approved
college or scientific school, and the knowledge of French. German. Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the college or scientific schools where they have studied, as to the courses pursued In physics,
chemistry and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or
science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school will be required (1) to pass, at the
beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University. (21 then
to pass exnniinations enuivaleut to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University,
and (.3) to fin-iiish satisfactory certificates that they have had the requisite laboratory training as specified aliove. It is expected that only in very rare
instances will applicants who do not possess a degree In arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING.
Applicants for admission to advanced standing must furnish evidence (1) that the foregoing terms of admission as regards preliminary training have
been fulfilled, (2) that courses equivalent in kind and amount to those given here, preceding that year of the course for admission to which application
Is made, have been satisfactorily completed, and (3) must pass examinations at the beginning of the session in October in all the subjects that have been
already pursued by the class to which admission is sought. Certificates of standing elsewhere cannot be accepted in pliice of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

since the opening of the Johns Hopkins Hospital in 1SS9, courses of instruction have been offered to graduates In medicine The attendance nnon
these courses has steadily iuore.ised with each succeeding year and indicates gratifying appreciation of the special advantages here afforded With the
completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the
aca.lemic year than that hitherto selected. It is. however, believed that the period now chosen for this purpose Is more convenient for the m.njoritv of
those desiring to take the courses than the former one. The special courses of instruction for graduates In medicine are now given annually during" the
months of May and June. During April there is a preliminary course in Normal Histology. These courses are in PptholO''v Bacteriolo-n- ciinical Mlcro-
'^'■"J"^, ?*''','"''" ^''?'|'S!°t .*'",'"S''ry- Gynecology, Dermatology, Diseases of Children. Diseases of the Nervous System. Genito'-Urinarv Diseases, Larvngologv
and Rhlnology. and Ophthalmology and. Otology. The instruction is intendi-d to meet the requirements of practitioners of medicine, and is almost wholly
of a practical character. It includes laboratory courses, demonstrations, bedside teaching, and clinical instruction in the wards, dispensary, amphitheatre,
and operating-rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the
several instructors that they are [.repared to profit by the opportunities here offered. The number of .students who can be accommodated in some of the
practical courses Is necessarily limited. For these the places are assigned according to the date of application
regl^n""'"^ October a select number of physicians will be admitted to a special class for the study of the Important tropical diseases met with In this

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.

11»4

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 121-l-i3-T2:3.

PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.

THE JOHNS HOPKINS HOSPITAL REPORTS.

Volume I. 423 pages, 99 plates.

Volume II. 570 pages, with 28 plates and figures.

Volume III. 766 pages, with 69 plates and figures.

Volume IV. 504 pages, 33 charts and illustrations.

S. Thayer, M. D..

Report on Typlioid Fever.

By William Osler, M. D.. with additionnl papers by W.
and J. Hewetson, M. D.

Report in Xeurologry.

Dementia Paralytica in the Xegro Race: Studies in the Histology of the
Liver: The Intrinsic Pulmonary Nerves in Mammalia : The Intrinsic
Xei-ve Supply of the Cardiac Ventricles in Certain Vertebrates: The
Intrinsic Nerves of the Submaxillary Gland of .l/irs yuKsiUlii^: The
Intrinsic Nerves of the Thyroid Gland of the Dog: The Nerve Elements
of the Pituitary Gland. By Hekry J. Berkley, M. D.

Report in Surgery.

The Results of Onerations for the Cure of Cancer of the Breast, from
June, 1S89, to January, 1804. By AV. S. Halsted, M. D.

Report in Gynecology.

Hydrosalpinx, with a report of twenty-seven cases: Post-Operative Septic
Peritonitis: Tuberculosis of the Endometrium. By T. S. Cullen, M. B.

Report in Patliology.

Declduoma Mnlignum. By J. Whitridge AVilliams, M. D.

Volume V. 480 pages, with 32 charts and illustrations.

CONTEXTS:
The Malarial Fevers of Baltimore. By W. S. Thayer. M, D., and J. Hewet-

S0S-. M. D.
A Study of some Fatal Cases of JIalaria. By Lewellys F. Barker, M. B.

Stndies in TypUoid Fever.

By William Osler, M. D., with additional papers by G. Blumer. M. D.,
Sjmo.v Flexxer, JI. D., Walter Reed, il. D., and H. C. Parsoxs, M. D.

Volume VI. 414 pages, with 79 plates and tigureg.

Report in Nenrology,

Studies on the Lesions produced by the Action of Certain Poisons on the
Cortical Nerve Cell (Stndies Nos. I to V). By Henry J. Berkley, M. D.

Introductory. — Recent Literature on the Pathology of Diseases of the Brain
by the Chromate of Silver Methods: Part I.— Alcohol Poisoning.— Exper-
imental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alco-
holl. 2. Experimental Lesions produced by Acute Alcoholic Poisoning
(Ethyl Alcohol): I'art II. — Serum Poisoning. — Experimental Lesions in-
duced by the Action of the Dog's Serum on the Cortical Nerve Cell:
Part HI.— Ricin Poisoning.— Experimental Lesions induced by Acute
Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin
Poisoning: Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical
Nerve Cell nroduced by the Toxlne of Experimental Rabies; Part V. —
Pathological Alterations in the Nuclei and Nucleoli of Xerve Cells from
the Effects of Alcohol and Hicin Intoxication; Xerve Fibre Terminal
Apparatus: Asthenic Bulbar Paralysis. By Hexry J. Berkley, M. D.

Report in Pathology.

Fatal Pueroeral Sepsis due to the Introduction of an Elm Tent.

Thomas S. Cullex. M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death, Probable

Migration of Ovum and Spermatozoa. By Thomas S. Cl'llex., M. B., and

G. L. Wilkins. M. D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Culles, M. B.

A Bacteriological and Anatomical Study of the Summer Diarrhoeas of

Infants. By William D. Booker. M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flexxer. M. D.

Volume VII. 537 pages with illustrations.

I. A Critical Review of Seventeen Hundred Cases of Abdominal Section
from the standpoint of Intra-peritoneal Drainage. Bv J. (}. Clark,
M. D.
n. The Etiology and Structure of true Vaginal Cysts. By James Erxest
Stokes. M. D.

III. A Review of the Pathology of Superficial Burns, with a Contribution
to our Knowledge of the Pathological Changes In the Organs in cases
of rapidl.v fatal burns. By Charles Russell Bardeex. M. D.

IV. The Origin. Growth and Fate of the Corpus Luteum. Bv J. G.
Clark. M. D.

V. The' Results of Operations for the Cure of Inguinal Hernia. By
Joseph C. Bloodgood, 51. D.

Volume VIII. 553 pages with illustrations.

On the role of Insects. Arachnids, and Myriapods as carriers in the spread
of Bacterial and Parasitic Diseases of Man and Animals. By Georoe
H. F. XuTTALL, M. D., Ph. D.

Studies in Typlioid Fever.

By William Osler. SI. D., with additional papers bv J. M. T. Fixxey, M. D..
S. Flexxer, M. D., L I'. Lvox, M. D., L. P. Hamburger, M. D., H. W.
CusHixG. M. D.. J. F. Mitchell, M. D., c. N. B. Camac. M. D.. N R. Gwtn,
M. D., Charles P. Emeksox. M. D., H. H. Yuusg, M. D.. and W. S. Thater, M. D.

Volume IX. lOGO pages, 66 plates and 210 ntlier Illus-
trations.

Contriliutions to tlie Science of Medicine.

Dedicated by his Pupils to William Henry Wo,ch, on the twenty-fifth anniversary
of his Doctorate. This volume contains 38 separate papers.

The set of nine volnnies Ti'ill he sold for fifty dnlliirs. net.
A'olniiies I and II -nil! not l»e sold separjitely. A'oliinies III,
IV, V, VI. VII and A'lII will he sold for tive d<illars, net,
each. A'olliiiie IX T%'ill he sold for ten dollars, net.

SEPARATE MONOGRAPHS REPRIXTED FROM THE JOH\S
HOPKIXS HOSPITAL, REPORTS.

Stndies in Derniatology, By T. C. Gilchrist, M. D., and Emmet Kixford,

M. D. 1 volunu' of 104 pages and 41 full-page plates. Price, in paper, $3.00.
The Malarial Fevers of Baltimore. By W, S. Thayer, M. D., ami J.

Hewetsox. M. D. And -\ Study of some Fatal Cases of Malaria.

By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, $2.75.

Pathology of ToxaIl»umin Intoxications. By Simon Flexxer, M. D.

1 volume of 130 pages with 4 full-page lithographs. Price, in paper, $2.00.

Stndies in Typhoid Fever. I, II. By William Osler, M. D.. and others.

Extracted from \'ols. I\' and V of The Johns Hopkins Hospital Reports. 1

volume of 4S1 pages. Price, in paper. $3.00.
Stndies in Typhoid Fever. III. By William Osler, M. D., and others.

Extracted from Volume VIII of The Johns Hopkins Hospital Reports. One

volume of 400 pages. Price, in paper, $3.00.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice;
abstracts of papers read and other proceedings of the Medical Society of the Hospital,
reports of lectures, and other matters of general interest in connection with the
work of the Hospital. It is issued monthly. Volume XH is now in progress. The
subscription price is $1.00 per year. The set of twelve volumes will be sold for

Orders should be addressed to

The Johns Hopkins Press, Baltimore, Md.

STUDIES IN TYPHOID TEVER. .

SERIES I-II-III.

Tlie papers on Tvphoicl Fever, edited by Professor William Osier, M. D., and printed in Yoliiines lY, V and VIIT of
The Johns Hopkins Hospital Reports have been brought together, and bound in cloth.

The volume includes thirty-five papers by Doctors Osier, Thayer, Hewetson, Blnmer, Flexner, Read, Parsons, Finney,
Gushing, Lyon, Mitchell, Hamburger, Dobbin, Camac, Gwyn, Emerson and Young. It contains 776 pages, large octavo,
with illustrations. It gives an analysis and study of the cases of Typhoid Fever in The Johns Hopkins Hospital for the
past ten years.

The price is $5.00 per copy. Onlj' a few copies of the volume are on sale. Those wishing to purchase should address
their orders to the Johns Hopkins Press, Baltimoee, Maryland.

The Johns H(rpkins Hofpilal BuUetiiis are issued movlhly. They are prtofed hy THE FEIEDEXWALD CO., Baltimore. Single eiyidcs may be prncnred from
Messrs. CUSHINO A CO. and the BALTIMOIiE NEWS CO.. Baltimnre. Subscriptions, $1.00 a ycor. may he addressed to the pvhHshcr.'. THE JOHNS HOrKINS
PRESS, BALTIMORE; tingle copies xcill he sent ty mail for fifteen cents each.

BULLETIN

THE JOHNS HOPKINS HOSPITAL

Vol. Xll.-No. 124.]

BALTIMORE, JULY, 1901.

[Price, 15 Cents.

CONTENTS.

PAGE

A Case of Arterial Disease, Possibly Periarteritis Nodosa. By

Florence R. Sabin, M. D., . '. 105

Typlioiil Iiifeetiou Witboiit Lesion of the Intestine. A Case of
Iheniorrhai^ie 'I'yphoid Fever With Atyi'ieal Intestinal Lesions.
By Eugene L. Opie, M. D., and V. n. Bassett HIS

Frequency of Typhoid Bacilli in the Blood.
M. D

By RuFUs L Coi.e,

303

A Portable Oiieratiug Outfit. By J. M. T. Finnev, i\I. D., and Omak

Pancoast, M. D., 30li

Uleer of the Stomach Caused by the Diphtheria Baeillus. By
William R. Stokes, M. D.,

3011

Ovarian Organotherapy. By William Kuusen, M. D., .... 313
Jesse William Lazear Memorial, 315

Proceedings of Societies:

The Johns Hopkins Hospital Medical Society, 310

The Intrinsic Blood-Vessels of the Kidney aud their Significance
in Nephrotomy [Mr. BkodelI; — A Case of Arterial Disease,
Possibly Periarteritis Nodosa [Dr. Sabin]; — Typhoid Infection

Without Lesion of the Intestine. A Case of H;emorrhagic
Tyiihoid Fever With Atypical Intestinal Lesions I Dr. Opie aud
Mr. Bassett] ; —Report Upon B. Mortiferus [Dr. IIarius]; —
Two Cases of Amoebic Dysentery in Children [Dr. Amiseug); —
Exhibition of Surgical Cases [Dr. Mitchell] ;— Healed Amoebic
Abscess of the Liver, and Amoebic Abscess of the Lung. Exhi-
bitions of Specimens [Dr. Opie]; — Exhibition of a Case of
Osteoma of External Auditory Canal [Dr. Randolph] ; — Sus-
pension of the Kidney. An Extensive Vesico-Vaginal Fistula
[Dr. Kelly]; — Exhibition of Medical Cases. Chronic Jaundice
with Xanthoma Multiplex [Dr. Osler] ; — A Case of Arsenical
Neuritis [Dr. Sabin]; — A Case of Pemphigus Vegetans [Dr.
Hambukgek]; — The Frequency of Typhoid Bacilli in the Blood
[Dr. Cole].

Summaries or Titles of Papers by Members of the Hospital and

Medical School Staff Appearing Elsewhere than in the Bulletin, 331

Notes on New Books, 323

Books Received, 330

A CASE OF ARTERIAL DISEASE, POSSIBLY PERIARTERITIS NODOSA.

By Florence R. Sabin, M. D.

Mrs. R. G., £et. 32, was admitted to the Johns Hopkins
Hospital on October 21, 1900, in the service of Dr. Osier,
to whom I am indebted for the opportunity of reporting
(lie case. She died October 2(5, 1900. She complained of
weakness and stomach trouble. The family history was
unimportant. She had been married eleven years, had had
three children and no miscarriages. She had had measles
and possibly malaria. She was a well, strong woman up to
four years previous, when she had an attack of dropsy. For
this she was treated at the St. Luke's Hospital, New York
City, where the diagnosis of chronic nephritis and endocarditis
was made. Since that illness she had never felt well, had
iiad shortness of bieath and amcnorrhoea. There was no
history of syphilis. She had never taken alcoliol.

The present illness began in August, 1900, two and a half

' Read before the Johns Hopkins Hospital Medical Society, December
17, 1!)00.

months before admission. During the summer she had loss
of appetite, indigestion, vomiting and weakness. In August
she had attacks of severe shooting pains in the arms aud legs.
She said that the veins in her arms and legs were swollen and
painful to the touch. At the same time she had pain in the
epigastric region. On the 19th of September she went to
bed with an attack of vomiting which continued four or five
days. From that time on, 5 weeks, she had been almost
confined to bed. She had had occasional attacks of vomiting,
the vomitus being green and containing undigested food but
no blood. The bowels had been constipated, the stools light
yellow. At the time of admission, she was having diarrhoea
with 2 to 4 stools a day. Two weeks before admission her
flesh became tender to the touch, and she was unable to
move in bed on account of pain. She had lost weight and
strength rapidly. Once during the attack she had a rash
like measles over the trunk. It lasted four or five days.

196

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

She had had frequency of micturition and occasional swelling
of the feet. The urine had been scanty in amount.

On admission she looked extremely ill. There were ema-
ciation, anaemia and asthenia. The skin was sallow, the lips
and mucous membranes bloodless, the sclerotics blue. There
was a brownish pigmentation of the face, hands and arms.
The small muscles of the hands were atrophied. The lungs
were negative, the heart not enlarged and its sounds were
normal, save for a soft systolic murmur heard best in the
pulmonic area. The arteries showed an extreme grade of
annular sclerosis. Both radials were calcified so that no
pulsation could be felt at the wrist. The pulse was taken at
the elbows. The brachials were beaded and could be felt as
a series of annular rings. The mammary artery was calcified.
The right one could be seen as a string of beads crossing three
or four ribs. (Dr. Osier.)

In each popliteal space there was a row of small, hard
nodules about the size of a split pea. Two were excised and
proved to be made up of lime salts. They were directly
under the skin, where the vessels were too small to make out
any relations. Scattered over the abdomen were similar
nodules; they felt softer and seemed more in the muscle than
in the skin. Just above the umbilicus and over both tubera
ischii were areas of firm induration in the skin measuring
about 4 by 5 cm. Those over the ischia were nodular. She
described them as warts.

The abdomen was sunken, the walls so thin that the coils
of intestine were plainly seen. There was extreme tender-
ness in the epigastrium. The liver dulness extended from
the 5th rib to a point 3.5 cm. below the costal margin in the
mammillary line, and 9.35 cm. below the tip of the ensiform
in the median line. The edge of the spleen was palpable
1 cm. below the costal margin. The stomach measured 23.5
by 11 cm. after inflation; it was displaced so that its lower
border was 7.5 cm. below the umbilicus. TTo masses could bo
made out. Vaginal examination was negative, except that
there was one small nodiile on the vulva. There were no scars.
The cervix and uterus were small and there were no masses in
the pelvis. There was a slight purulent discharge in which
no gonocoeei could be found. There was no glandular en-
largement. The patellar reflexes were exaggerated.
. The blood examination was as follows: On October 33
the fresh specimen showed considerable variation in the size
and shape of the red cells, the average diameter being less
than normal. The red corpuscles were extremely pale.
There was much fibrin and the blood platelets were extra-
ordinarily increased. (Dr. Thomas B. Futcher.') October 23,
haemoglobin, 33 per cent; red blood corpuscles, 1,773,000;
white blood corpuscles, 50,000. The differential count of
313 leucocytes showed: polymorphonuclear leucocytes, 91 per
cent; small mononuclear leucocytes, 2 per cent; large mono-
nuclear leucocytes, .9 per cent; transitional leucocytes, 2 per
cent; eosinophilic leucocytes, 3 per cent; two normoblasts.
October 35, white blood corpuscles, 81,000. October 26,
hsemoglobin, 31 per cent; red blood corpuscles, 1,704,000;
whit(! blood corpuscles, 116,000.

The fresh sijecimen was the same as before, the increase in
leucocytes being due to the jjolymorpiionuclear forms. The
blood examination showed then a secondary anannia and a
pure leucoeytosis.

The temperature was subnormal throughout, the range
being 96° to 97.8°. This includes simply the last week of
the illness. At the same time the pulse was rapid, ranging
between 104 and 134. It fell to 90 on the day of her death.
The urine was scanty in amount, 180 cc. being the highest
record for the 34 hours. She had, however, from 2 to 4
stools a day. The specific gravity of the urine was 1010;
it was almost colorless and had a considerable trace of albu-
men and a few finely granular and epithelial casts. On
October 25 there was almost no urea in a 24-hour mixed
specimen. There were but four or five small bubbles of gas
generated in the sodium hypobromate solution. Notwith-
standing this low excretion of urea the mind was clear; she
was drowsy but awakened as soon as any one stepped to her
bed, and she was not in coma until four hours before death.

During her stay in the hospital her chief complaint was of
pain and burning in the stomach. This was worse on swal-
lowing when she said that she felt a burning like fire all the
way down. She had great thirst but little appetite. At
times the muscles of the arms and legs were tender to pres-
sure and again the skin over the hips became so sensitive that
she would cry out at the slightest touch. Pressure over the
epigastrium always made her cry out with jjain. Her sleep
was distui'bed, occasionally waking in fright. On the day of
her death there were subcutaneous lucmorrhages on the legs,
and the feet and hands became cyanoscd and cold. It is a
matter of great regret that no section could be obtained.
Ilcr peojile were strict Jews and took her home as she was
dying, evidently in dread of an autopsy. When she left the
hospital at 5 P. M. her mind was perfectly clear; she was
conscious when she reached home but soon fell asleep and
died in four hours without waking.

At first the case was considered to be Bright's disease with
secondary anamia but the presence of the nodules suggested
the necessity of further study, and it was found that the
clinical features of the disease corresponded with the case of
periarteritis nodosa, described by Kussmaul and Maicr in
1S66. A good account of this case was found in Albutt's
System of Medicine.

Four cases of periarteritis nodosa have been described. In
all of the lists in the literature, a fifth case of multiple
aneurisms due to syphilis and reported by Chvostek and
Weichselbaum in 1877, is incliuled.

Case I.' In 1866 Kussmaul and Maier described a hitliorlo
unknown arterial disease, which they called periarteritis
nodosa, associated with Bright's disease and progressive miis-
cular atrophy. The case was a young tailor, aged 37. His
illness lasted a little over a month. He complained of stag-
gering, chilly feelings with fever, and of having his hands
go to sleep. They describe him on admission as so sick that

' Kussmaul A. aud Maier, R.
484-518.

Dent. Arcli. f. klin.Med., 1806, Bd. i, S.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

197

the prognosis was made before the diagnosis, that on first
sight he was known to be a lost man whose days were few and
numbered. This was true of our case. Their case was ob-
served for one month, the entire duration was seven weeks.
The symjDtoms were as follows: pains in the muscles both
spontaneous and on pressiire, areas of hyperaesthesia of the
skin, great weakness which developed rapidly, loss of appetite,
pain in the abdomen, especially in the hypochondriac region,
and pain in the groins. There was great thirst, at first con-
stipation, later diarrhoea. Sleep was disturbed but the mind
was clear thronghout. A progressive paralysis developed,
beginning with the small muscles of the hands and gradually
including the entire body.

The signs were of extreme anaemia, a " chlorotie maras-
mus." The temperature range was 97.5°-102.5° F.; it was
never high and miich of the time there was no fever In con-
trast with the low temperature, the pulse was rapid, 113-133.
Heart and lungs were normal, liver and spleen not enlarged.
There was muscular atrophy beginning with the small muscles
of the hands. The urine was diminished in amount, of low
specific gravity, 1011-1019, and contained al^iumen and casts,
at first blood also. Three days before death small sulicuta-
neous nodules were felt over the breast and abdomen. These
had developed during the course of the disease.

A section was obtained in which the interest centred on
these nodules. They were found on the small and medium
sized arteries of the muscles and viscera; the heart and lungs,
liver, spleen, alimentary canal, kidneys and especially the
mesentery showed them, while the arteries of the brain, the
aorta and its branches were exempt.

Case II.' In 1878, Meyer described a case much like
Kussmaul and Maier's. It was a man, a^t. 27. He was sick
8 weeks, and was under observation must of this time. He
complained of pains in the neck, calves of the legs and
groins. There was a history of gonorrhoja and syphilis. He
showed extraordinary prostration. There were attacks of
pain in the stomach and pressure over it was unendurable.
The bowels were constipated. There were muscular pains
but no paralysis and no disturbance of sensation. The mind
was clear but toward the end he became irritable and restless.

The signs were extreme amcmia, a " chlorotie marasmus."
The pulse range was 92-108, the temperature reached 104°
in the early part of the disease, later the daily range was
from 98.8° to 101.8°, and finally it was continuously normal.
The heart and lungs were normal, the liver and spleen became
enlarged while under observation. The urine was decreased
in amount and showed albumen. There was transient oedema
of the feet and legs. The nodules were not found before
death. On section nodules were found with the same distri-
1 )ution as in Case I. Meyer regarded the nodules as aneurismS;

Case III.* Fletcher's case was a woman, set. 49. The
duration was about 2 months, and she was under observation

3 Meyer, P. Arcli. f. path. Anat. u. Pliys. u. f. kliii. Med., 1S78, Brt.
Ix.fiv, S. 277-319.

•" Fletcher, H. M. Beitr. z. path. Auat. u. z. alls;. Path., ,Iena, 1801, xi,
333-343.

at the Freiburg Clinic for the last 3 weeks. There was no
history of syphilis; her husband had died of tuberculosis.
She was fairly well nourished, and there was a peculiar staring
expresssion of the face. In our case a retraction of the upper
eyelids gave a staring expression. There was occasional vom-
iting and alternating constipation and diarrhoea. She had
cough and expectoration. The physical signs of the heart
were normal save a modification of the first sound at the
apex. There wei'e a few rales at the apices of both lungs.
The liver was small, the spleen large. The temperature range
was 98.6° to 104°, the pulse 96-138. The urine had a trace
of albumen and there was oedema of the feet and legs. No
note is made of anjEmia nor of a blood examination. The
case was thought of before death as either typhoid fever or
miliary tuberculosis.

Section showed no tuberculosis. Nodules were found in
all the viscera except the brain. The liver and spleen were
both enlarged. The autopsy was made by von Kahlden.

In 1894 von Kahlden ' saw a second case. It was a woman,
a>t. 52. The duration 12 weeks, but she was under observa-
tion only one day. She complained of fever, loss of appetite
and pain in the right hypochondrium. She had had sweat-
ing, pain in the arms and legs and great weakness. While
under observation she complained of the pain in the stomach
as a terrible burning. There was constipation. Sleep was
disturbed but the mind was clear. The signs were as follows:
the temperature was 99.8°, normal at the end; the pulse
was 140. The ana?mia was extreme, the skin being light
yellow. She had had transient redema of the face. The
physical examination is not given but the section showed no
enlargement nor valvular lesion of the heart. The lungs
were firm but not airless. The spleen was not enlarged.
Nodides were found in the muscles of the chest and tongue
and in all the viscera except the brain. They were most
.numerous in the mesentery.

These four cases were all proved by autopsy; and clinically
the case herein reported presents the same features. The
lesions of the disease are nodules on the arteries of the
muscles and viscera. The symptoms are associated with the
muscles, the circulatoiy system and the alimentary canal.
The muscles give pain, occasionally paralysis and atrophy;
the circulatory system aiijemia accompanied by an asthenia,
similar to that in Addison's disease. The pulse rate is rapid,
the temperature relatively low. There is fever at first, later
normal or subnormal temperature. The chief symptom is
gastrointestinal; namely, pain in the stomach accompanied
by loss of appetite, thirst, vomiting, constipation and diar-
rhoea. The signs of Bright's disease are present in the urine
but oedema is slight and transient and the mind is clear
throughout.

The cases have a wider interest than is due their rarity on
account of their pathology. Meyer and Eppinger consider
the nodules as aneurisms of the small and medium sized

5vou Kahlden, C. Beitr. z. path. Anat. \\. z. allg. Path., Jena, 189i,
XV, 581-601.

198

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

arteries. These aneurisms are considered by some to be of
syiohilitic origin. On the other hand, Chvostek, Wcichsel-
bainn, Fletcher and v. Kahlden think that the nodules arc
inflammatory, or allied to the iul'eetious grauulomata and
that the aneurisms are secondary to this process. It is a
matter of great regret that we could not secure an autopsy
in our case; the blood counts showing a pure leucocytosis
of a high grade point, it seems to me, toward the inflamma-
tory nature of the disease.

Discussion.

interesting that Dr. Osier and Dr.

Dk. Welcu. — It is
Sabin ai'e willing to make this diagnosis without an autopsy,
that is, that they consider the clinical picture sufficiently dis-
tinctive, with these nodules, to justify the diagnosis. I judge
from the summary of the histories of other cases that there
has been considerable uniformity in their characters. The
number seems, however, too small for more than tentative
conclusions.

TYWIOID INFECTION WITHOUT LESION OF THE INTESTINE. A CASE OF HJIMOIUIHAGIC
TYPHOID FEVER WITH ATYPICAL INTESTINAL LESIONS/

By Eugene L. Opie, M. D.,
Instructor in Pathology, Johns Hopkins University,

AND

V. H. Bassett.

{From the Pul/tulof/u-al Laboritlorij of the Johns Hopkins Uitu'ertiit^ otnl Hofpittd.)

The intestinal lesions of typhoid fever vary greatly in
extent and distribution. Swelling, necrosis and ulceration
of the Peyers patches are usually present throughout a con-
siderable proportion of the lower ileum, but at times a single
small ulcer may be the only macroscopic evidence of the
intestinal disease. Occasionally the small intestine appears
to be entirely unaffected, and hyperplasia and necrosis are
confined to the lymphatic apparatus of the large intestine.
Doubtless many mild cases run their course without any
idceration of the swollen patches. In a number of cases no
intestinal lesions have been found at autopsy, though the
clinical history has corresponded to that of typhoid fever and
after death the typhoid bacillus has been demonstrated in
the organs. To explain such cases one may assiune that the
organism can enter the- body through the intestine without
producing any lesion, or that the intestinal tract is not the
only path by which it can enter.

The following case, which has directed our attention to this
subject, resembles very closely those which have been de-
scribed as instances of typhoid fever without intestinal lesion:

A. L., female, aged ten years, was admitted to the Johns
Hopkins Hospital in the service of Dr. Osier July 14, com-
plaining of pain in the abdomen and weakness. Her family
history is unimportant. During the preceding spring she
had had measles and has since been slightly deaf but other-
wise has had good health. Her present illness began on
July 9 with malaise, headache and backache. The bowels
moved five or six times and she complained of some pain in
the abdomen. On the following day she felt feverish and
the diarrhcea and abdominal pain continued. Headache per-
sisted but the diarrhoea became less severe and the pain dis-

' Read before the Johns Hopkins Hospital Medical Society, Jauuary 7,
1901.

appeared. She vomited occasionally. There was no bleed-
ing from the nose.

On admission the child, who was well nourished, appeared
drowsy and uncomfortable and complained of some pain in
the abdomen. Her mind was clear. The pulse was of small
volume, easily compressible and not dicrotic, one hundred to
tile minute. Examination of the heart and lungs disclosed
no abnormality. There was no abdominal distention. A few
typical rose-spots were seen upon the abdomen and lower
thorax. The spleen was felt at the costal margin when the
patient lay on her side and its edge was firm. The tempera-
ture on admission was 103.4°. The Widal reaction was
obtained on the following day the blood serum diluted 1 to
50, causing agglutination of the typhoid bacillus.

During the first three days after admission the patient
complained of much abdominal pain. There was some dis-
tention of the abdomen and some tenderness which was most
marked in the epigastric region. Beginning on the 6th day
in the hosijital and persisting a few days pain and tenderness
were present in the right hypochondriac region and resistance
was here felt. During the first week fresh rose-spots con-
tinued to appear. The abdominal pain and tenderness dis-
appeared.

Beginning on the 13th day after her admission to the
hospital, bleeding occurred from the lips and nose; at first it
seemed as the results of irritation of these parts by continual
picking with the fingers. Crusts formed from which blood
oozed at times. Over the left cheek below the eye appeared
a number of small purpuric areas and ecchymosis occurred
into the skin about an excoriation over the right internal
condyle of the humerus. The blood, tested by Wright's coag-
ulation tubes, was found to coagulate in four minutes and
forty-five seconds. Bleeding from the nose in small amounts

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

199

was persistent. During tlic night of the 17th day after
admission, 60 cc. of bright red blood were passed from the
rectum and the following day two soft stools consisted almost
entirely of changed blood. The red corpuscles numbered
3,25G,000, white corpuscles 3350; the hemoglobin was 41
l^er cent.

The note made on the 19th day of observation states that
the child seems very ill. The bleeding from the nose has
temporarily stopped. The mucous membranes are ansmic.
Nrmierous purpuric areas are scattered over the face, over
the posterior surface of the right arm and in small numl)cr
over the front and back of the trunk.

The stools for four days following the first passage of
blood from the rectum contained changed blood in small
amounts and there was some abdominal pain but no tender-
ness nor distention. On the 21st day bleeding from the
nose again occurred. The blood examination was as follows:
red blood corpuscles 1,708,000, white corpuscles l-'j.OOO.
haemoglobin 26 per cent, coagulation time five and a half
minutes. There was repeated vomiting of swallowed blood.
New purpuric spots had ajipeared upon the cheeks and
shoulders. The patient died with gradually increasing weak-
ness on the 2lst day after admission to the hospital, the 26th
day of her illness.

During the first few days in the hospital the temperature
was almost continuously between 103° and 10-1°, while sul)-
sequcntly it varied between 99° and 104.-5°. The urine con-
tained a trace of albumin and an occasional granular cast.

Autopsy. — The body is that of a well nourished child 12S
cm. in length. Over the face are scattered purple ecchymotic
spots, the largest 1.5 cm. across. Similar purpuric areas are
s]iarsely distributed Tipon the trunk, upon tlie inner surfaces
of the arms and upon the legs.

The peritoneum, plexirs and pericardium are normal in
appearance.

The heart weighs 120 grm. Below the epicardium of both
ventricles are numerous ecchymoses about 0.5 cm. across.
The muscle is pale brown in color and into its substance arc
a few small luemorrhages. Below the endocardium of both
ventricles but most numerous on the right side are small
ecchymotic spots. The valves are normal. The lungs have
a grayish-pink surface upon which are scattered areas of
deep red color. The tissue is nowhere consolidated.

The liver weiglis 820 grm. The tissue has a brownish-red
color; the lol)ulation is well marked. The gall-bladder con-
tains yellow bile. The spleen weighs 180 grm. and measures
11.5x7.2x4.2 cm. The capsule is smooth. The organ is
soft in consistency. The pulp is of a very deep brownish-rod
color and the Malpighian bodies are well seen.

The stomach contains a small quantity of dark brown fluid
material. Its mucosa is thickly studded with small bright
red ecchymoses. The duodenum contains a small amount
of bright yellow fluid. The jejunum contains brownish, par-
tially clotted and slightly changed blood, and in the ileum,
particularly in its lower part, is reddish-brown fluid in which
are clotted particles. Passing downward Beyer's patches are

first seen in the lower part of the jejunum and throughout
the ileum they are numerous. Their surface is raised but
little above the general level and is very slightly nodular;
they are conspicuous only because they have remained un-
changed while the surrounding mucosa is stained a brownish
color by the intestinal contents. Above the iloociecal valve
is a very large Peyer's patch 15 cm. in length but otherwise
presenting the appearance seen elsewhere. Solitary follicles
are visible as small, slightly elevated nodiiles. The appen-
dix vermiformis is normal. The solitary follicles of the
large intestine which are readily seen are often marked by
a minute central point of pigmentation.

Lymphatic glands in the mesentery, above the pancreas,
and on either side of the aorta, are enlarged, often 1.5 cm.
in length, soft and succulent. Some of the larger show on
section a central dull red area surrounded by a zone of yel-
lowish-gray color. The ileo-colic glands are enlarged.

The kidneys together weigh 200 grm. The capsule tears
away readily and leaves a smooth pale surface thickly studded
with bright red ecchymotic points. Throixghout the cortex
are minute liKniorrhages. Several small ecchymoses are
seen below the mucosa of the bladder. The bone marrow of
the femur is of deep red color. The other organs are nor-
mal.

Microscopical Examination. — The liver contains scattered
foci of necrosis within which are proliferated cells with round
or irregular nuclei. The sinuses of the mesenteric and retro-
peritoneal lymphatic glands are distended with large cells of
an ejiithelioid type, many of which contain ingested lympho-
cytes. In places these cells are necrotic and their nuclei no
longer stain. Sections through several Peyer's patches of the
lower ileum show no hyperplasia nor is there any infiltration
of the muscularis with lymphoid cells. In some sections are
found collections of a few large cells of an epithelioid type.
The solitary follicles of the large intestine apjiear to be
normal.

Bacteriological Examination. — Agar-agar plate cultures
were made from the heart's blood, lung, liver, gall-bladder,
spleen and kidney. The bacillus coli communis was obtained
from the liver and kidney. From the liver, gall-bladder and
kidney was obtained a motile bacillus of similar morphology
and cultural characters but with the following peculiarities:

On potato a moist glistening appearance is noticeable at
the end of twenty-four hours; at the end of two days the
gi'owth is visible as a thin yellowish-white film. Control
cultures of the typhoid bacillus from other sources showed a
similar growth upon potato of the same stock. Milk tinted
with litmus is slightly acidified and is not coagulated. In
litmus whey (Petruschky's medium) at the end of seven days,
the acid formed in 10 ee. of the medium is equivalent to
0.6 ec. of one-tenth normal sodium hydroxide solution.
Grown in glucose agar-agar the organism forms no gas.
Tested in fermentation tubes it formed no gas with glucose,
lactose or saccharose; with glucose the reaction of the medium
was acid at the end of forty-eight hours, while with lactose
and saccharose an alkaline reaction was retained. Indol was

200

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 134.

not formed in Dunham's solution at tlie end of a week.
Tested with the blood senim of a typhoid patient giving the
agglutination reaction with a typhoid bacillus from another
source, a positive agglutination test was obtained; with serum
diluted 1 to 200 the reaction began in 5 to 10 minutes and
clumping and cessation of motility was complete in 30 to 60
minutes. The organism gave the same reaction when tested
with the blood serum of a rabbit immunized to the typhoid
bacillus; with serum diluted 1 to 200 clumping occurred in
15 to 30 minutes. The characteristics enumerated serve to
identify the organism as the typhoid bacillus.

The ease resembles those which have been reported as in-
stances of typhoid infection without intestinal lesions. The
clinical course was that of typhoid fever; during the first two
weeks rose-spots were present, the spleen was enlarged and
the temperature curve was that usually observed. A positive
Widal reaction confirmed the diagnosis. The disease did not
appear to be of a very severe type until the occurrence of
repeated haemorrhage, persistent epistaxis, pui-puric ecchy-
moses, and hemorrhage from the bowel, finally producing
grave secondary anaemia. At autopsy the usual intestinal
lesions of typhoid fever were not found; there was no ulcera-
tion of the mucosa and the Peyer's patches and solitary fol-
licles were so slightly changed that the alterations present
might readily have been overlooked had not typhoid infection
been suspected. The solitary follicles of the large intestine
were marked by minute points of pigmentation. The his-
tory gives evidence that the intestine was implicated early in
the disease since during the first and second weeks there
were diarrhoea, abdominal pain and tenderness, and some
distention. The presence of blood in the stools during the
last week, in association with haemorrhage from the nose and
into the subcutaneous, subserous and subcutaneous tissues,
was not the result of ulceration since careful examination
showed the mucosa to be everywhere intact. In part at
least the changed blood in the stools may have been swal-
lowed from the nose. Though the intestinal lesions of ty-
phoid were almost entirely absent, the mesenteric lymphatic
glands and the spleen were enlarged and the liver contained
foci of necrosis. The bacteriological examination of the
case is sufficiently complete to demonstrate that the child
died with typhoid fever complicated by a condition resem-
bling purpura hsemorrhagica ; the case is one of ha?morrhagic
typhoid fever.

The disease did not run its course without intestinal lesions.
The early diarrhoea and abdominal pain, the enlargement of
the mesenteric lymphatic glands, the slight swelling of the
Peyer's patches and solitary follicles of the small intestine
and the presence of minute points of pigmentation upon the
solitary follicles of the large intestine indicate that the in-
testine was not wholly unaffected. These lesions were slight
and at the time of death had almost completely subsided.
Doubtless hyperplasia of the lymphatic apparatTis of the in-
testinal wall was more marked during the first weeks of the
disease.

The number of cases of so-called typhoid fever without
intestinal lesion is not large. The earlier cases are collected
by Chiari and Kraus," who have recorded six instances of
what they regard as pure typhoid septicaemia, invasion of the
internal organs without demonstrable intestinal lesion. Flcx-
ner and Harris' reviewing the literature regard as doubtful
the earlier cases, those of Banti,* Karlinski ° and Guarnieri,"
since the means of identifying the typhoid bacillus then avail-
able are inconclusive. Ophiils ' has in the last year again
reviewed this literature. In some of the reported cases he
believes the organism entered the body by the usual path,
while in others the published reports do not exclude the possi-
bility that lesions were present but subsequently subsided.
He thinks that the necessary means now at our disposal for
the diflierential diagnosis between the typhoid bacillus and
allied forms were employed only in the case of Flexner and
Harris, in the three cases of Lartigau' and in the one re-
ported by himself.

Cases reported as instances of typhoid fever without
lesions of the intestine fall into several groups, (a) In
many cases the typhoid bacillus has not been identified with
certainty so that the nature of the disease is doubtful. (6)
In some of the cases which are cited as examples of the con-
dition slight lesions of the intestine are described, (c) Pri-
mary tuberculous ulceration of the intestine has, it appears
in at least three cases, afforded a portal of entry for the
typhoid bacillus, characteristic intestinal lesions of typhoid
fever being absent, (d) Death may have occurred so long
after the onset of the. disease that opportunity has been given
for the subsidence of preexisting lesions, (c) In a small
number of cases death has occurred during the first four
weeks of the disease and careful bacteriological examination
has demonstrated the presence of the typhoid bacillus in the
organs after death.

Though we cannot deny the possibility that typhoid fever
may occur without lesions of the intestine, much of the evi-
dence furnished by the published reports is inconclusive. In
many i-eported instances the demonstration of the typhoid
bacillus has been incomplete, insufficient means having been
used to identify it. The cases of Banti and of Guarnievi, as
stated by Flexner and Harris, belong to a period at which the
difficulty of separating the typhoid bacillus from allied forms
was not recognized.

Karlinski ° has recorded three cases of typhoid fever with-
out intestinal lesion, certainly a rare condition, all of which
were under observation within a period of two months. The

'Zeitsch. f. Heilkunde, 1897, xviii, p. 471.

'Bulletin of the Johns Hopkins Hospital, 1S!)7, viii, p. 2.59.

••Riforma medica, 1SS7; Ref. Baumgarten's Jahresbeiiclit, 1S88, iv,
p. 148.

'Wiener med. Wochenscli., 1801, xli, pp. 409, .511.

' Riv. gen. di clin. med. ; Ref. Baumgarten's Jahresbericht, 1892, viii,
p. 334.

iNew York Med. Jour., 1900, Ixxi, p. 728.

8 Bulletin of the Johns Hopkins Hospital, 1899, x, p. 55, and New York
Med. Jour., 1899, !sx, p. 158.

' Loe. eit.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

201

first two cases which were admitted to the same ward within
a few days died on tlie twenty-tliird and twenty-second day
of their disease. Tlie third patient, who was convalescent
from a minor operation upon tiie finger, acted as an attendant
upon the first two and subsequently contracted a similar
disease. The clinical course in none of these patients re-
sembled typhoid fever, and of the second in which a rash
resembling rose-spots was present upon the trunjv, neck and
extremities, Karlinski states that had he not found the ty-
]ilioid bacillus in the organs after death he would have re-
garded tlie case as one of typhus fever. In the three cases
the spleen was very greatly enlarged but, except in the third,
no intestinal lesions were found. In the lower ileum of the
third patient, who died on the seventeenth day of his illness,
four pigmented scars were present and these Karlinski thinks
were the results of typhoid fever, Init since the patient died
during the third week it is improbable that they represented
healed ulcers occurring during the fatal attack. From the
spleen of all the cases and from other organs in the second
and third Karlinski cultivated an organism which he believed
to be the typhoid bacillus. The same organism he states was
found repeatedly during life in blood from the third patient.
As a means of identifying the typhoid bacillus Karlinski de-
pended upon the character of the growth on potato, in the
light of our present knowledge a very uncertain method. It
seems probable that the three cases which Karlinski regarded
as typhoid septiceemia were in reality, as he himself suggests,
instances of typhus fever.

Beatty '" describes the case of a man who suffered for six
days with hematuria and jaundice. The intestine presented
nothing abnormal. He mentions without details that the
typhoid bacillus was found at autopsy and concludes tluit this
case as well as a second resembling it but with no bacterio-
logical examination, were instances of typhoid fever without
intestinal lesions. In three of the six cases which Chiari and
Kraus regard as instances of pure typhoid sopticjemia the
typhoid bacillus was not isolated from the organs, though a
positive Widal reaction was obtained witli the blood serum.

DuC'azal " has recorded the case of a man who died with
dnulilc pneumonia on the twenty-first day of his illness.
1'he clinical course resembled that of typhoid fever; rose-spots
were present and before death were extraordinarily confluent
over the thorax and abdomen. The abdomen was greatly
distended but there was no tenderness. At autopsy the spleen
was much enlarged but there was no alteration of the intes-
tine nor of the mesenteric lymphatic glands. From the spleen
was obtained an organism having the cultural properties of
the typhoid bacillus, but in the absence of the agglutination
test its identity may be doubted. The patient of Pick " died
on the twenty-fourth day of his illness; a positive agglutina-
tion reaction was obtained with the blood serum. No intes-
tinal lesions were noted nor was the spleen enlarged, but the

'"Dublin Jour, of Med. Science, 1897, 3rd ser. cecii., p. 97.

" Bull et mijm. de la Soc. mod. des ITop. de Paris, 180H, 3 s,, x, p. 243.

'•' Wiener klin. Woelienseb., 1807, x, p. 82.

author states without giving details that the bacteriological
examination demonstrated a typlioid infection.

The reports of several instances of so-called typhoid fever
without implication of the intestine show that slight lesions
were present. To this gToup belongs the case of Nicholls and
Keenan." The solitary follicles of the ileum were swollen,
congested and of slaty color; the Peyer's patches were en-
larged. The recently reported case of Ophiils " was not en-
tirely witliout lesions of the intestine. The appendix vermi-
formis was the seat of well marked inflammation, and micro-
scopic examination showed hyperasmia and enlargement of
the lymphatic follicles; the epithelium was absent in places.
Atypical cases of typhoid fever with only a single intestinal
ulcer occur. Chiari and Kraus cite such a case reported by
Banti.

Of considerable interest are several cases in which the
typhoid bacillus was demonstrated in the organs, and though
there were no characteristic intestinal lesions of typhoid fever
the intestine was the seat of tuberculous ulceration. They
seem to show that the typhoid bacillus can enter the body
through pre-existing lesions of the intestinal canal. Guinon
and Meunier '° describe the case of a boy, eight years of age,
who came under observation with symptoms of pulmonary
tuberculosis. After several days rose-spots appeared, the tem-
perature curve assumed the character present in typhoid fever
and a positive Widal reaction was obtained. The autopsy
disclosed generalized tuberculosis and tuberculous ulcers
were found in the intestine. The typhoid bacillus was
isolated from the spleen, from fluid in the pleura and from
the lung. Lesions of typhoid fever were not found. Chiari
and Kraus record two similar cases occurring in adults.
Death occurred with chronic pulmonary tuberculosis, and
tuberculous ulcers were present in the intestine but there
were no lesions of typhoid fever. In the first case the ty-
phoid bacillus was obtained from the gall-bladder and from
the enlarged lymphatic glands, while in the second case the
same organism was grown from the gall-bladder though cul-
tures from the other organs remained sterile. In the latter
case the blood serum during life diluted 1 to 10 agglutinated
the typhoid bacillus, that from the femoral vein at autopsy
diluted 1 to 30 produced the same effect. Such cases cannot
be grouped with those in which the intestine appears to be
healthy, since it is probable that the pre-existing intestinal
lesion was the portal of entry for the organism.

In a certain proportion of the published cases the clinical
history, the presence of the Widal reaction during life and
the demonstration of the typlioid bacillus in the organs after
death leave little doubt of the existence of typhoid infection
though the intestine appeared to be normal. Doubtless many
cases of typhoid fever run their course without intestinal ul-
ceration, the primary hyperplasia of the lymphatic follicles
subsiding without any loss of substance. Chiari and Kraus in

'3 Montreal Med. .lour,, IS98, xxvii, p. 0.

» Loc. cit.

"Le Bulletin medicale, lSii7, xi, p. 313.

202

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

their article upon atypical typhoid and typhoid septicaemia
record three cases in which death occurred with broncho-
pneumonia during the thii'd or fourth week; the lymphatic
follicles of the intestinal wall were swollen but were not ulcer-
ated. In several cases reported as instances of typhoid fever
without lesion of the intestine death, occurring many weeks
after the onset of the disease, was the result of some compli-
cation or sequela, and opportunity was given for the restitu-
tion of swollen lymphatic tissue. Since we are familiar with
the persistence of the typhoid bacillus for long periods in the
body, it is not surprising that the organism was demonstrated
in the organs after death. To this group belongs the case of
Kuhnau," whose patient died with suppurative nephritis and
cystitis on the fifty-eighth day of her illness after having
undergone an attack of facial erysipelas. In one of the eases
of Chiari and Kraus death took place on the forty-third day
of the disease with multiple abscesses caused by the staphy-
lococcus pyogenes aureus; the typhoid bacillus was found only
in the urinary bladder. The third case which Lartigau ''
reports is that of a woman who, four months before her fatal
illness, suffered with an acute febrile disease diagnosed typhoid
fever. Death followed an operation for extrauterine preg-
nancy. The typhoid bacillus and the streptococcus pyogenes
were isolated from the uterus. The case reported by Flexner
and Harris '" is that of a man who died two months after the
onset of his fatal illness with thrombosis of the pulmonary
artery to the lower lobe of the right lung, gangrene of the
lung, perforation of the pleura and pyopneumothorax. The
typhoid bacillus was grown from the lung, spleen, liver and
kidney.

Cases in which death occurs early in the disease can alone
afford conclusive evidence that lesions of the intestine have
not been present. In the case which we have described death
occurred on the twenty-sixth day of the disease, yet at autopsy
very little evidence of intestinal lesion was found, though
there was reason to believe that the intestine had been impli-
cated. Cheadle and Lartigau have reported eases where
death occurred during the third, fourth or fifth week.

Cheadle '" reports the case of a boy three years of age.
Little doubt can be entertained that he suffered with typhoid
fever. A brother and a sister of the patient were coinci-
dently affected with the disease; rose-spots were present aTul
the Widal reaction was obtained. There was profuse diar-
rhoea during the first two weeks of the illness. Death oc-
curred on the thirty-second day. There was no idceration
of the intestine and the Peyer's patches appeared to be nor-
mal, but the mesenteric lymph glands were enlarged.
Cheadle states that the typhoid bacillus was cultivated from
the spleen. Lartigau has reported two very carefully
studied cases in which, though death followed in three
weeks the onset of symptoms, lesions of the intestine were

'«Berl. klin. WochenscU., 189G, xxxiii, p. 666.
" New York Med. Jour., 1899, Ixx, p. 1.58.
'8 Loc. cit.
" Lancet, 1897, ii, p. 2.54.

not found. The first case '" is that of a man 36 years
of ago who died on the twenty-first day of his illness.
There was at no time diarrhoea, abdominal pain nor tender-
ness. At autopsy the mesenteric lymphatic glands and the
spleen were enlarged and microscopically presented the
changes usually found in typhoid fever. The liver contained
necrotic foci and so-called lymphoid nodules. The typhoid
bacillus was carefully identified in the heart's blood, lung,
liver, gall-bladder and spleen. The second case," a man 51
years of age, died during the latter part of the third week of
his disease. Chronic interstitial nephritis, heart hypertrophy
and broncho-pneumonia were found at autopsy. Though the
intestine was free from lesion the typhoid bacillus was culti-
vated from the liver, gall-bladder, kidney and urine.

Few of the cases which have been cited furnish evidence
that the typhoid bacillus can enter the body in the absence
of intestinal lesions. In view of the cases of Cheadle and
Lartigau, perhaps those of DuCazal and Pick, this possi-
bility cannot be denied, but our case suggests that even in
these, lesions may have been present at the onset of the dis-
ease. The difficulty of proving that micro-organisms enter
through an exposed surface which remains healthy is ob-
viously great, and the study of this group of cases does
not conclusively prove its occurrence. On the other hand,
they do not show that the organism can enter by any path
other than the intestinal canal. From a histological study
of the lesions of typhoid fever Mallory "'' thinks it prob-
able that the lesions of the Peyer's patches, of the mesen-
teric glands and of the other organs are caused by toxic
products absorbed from the intestine by way of the lym-
phatic apparatus. Even should this explanation be accepted
the grouji of cases which we have studii'd does not demon-
strate beyond doubt, that these toxic products can enter
without producing any lesion of the intestinal wall. They
nevertheless emphasize the fact tliat the localization of the
typhoid bacillus is not exclusively in the lymphatic apparatus
of the intestine and the intestinal lesions of fatal cases nuiy
be so slight that at the time of autopsy they are no longer
recognizable.

Discussion.

Dr. Fiitcher. — I would like to say in regard to the clinical
aspect of this case that it illustrated very well the hopeless-
ness of endeavoring to counteract the tendency to bleeding
in these cases where a hsemorrhagic diathesis occurs, just as
one is almost helpless in hirmophilia. Wo tried all the usual
methods to stop the bleeding in this case; first, by attempting
to increase the coagulability of the blood by calcium chloride
administered internally and later by using carbonic acid gas
inhalations; second, by the local treatment, such as the local
application of suprarenal extract to the nostrils and the injec-
tion of a 5 per cent solution of gelatin in normal salt solution.

MBulletiii of tlie .Joliiis Hopkins Hospitiil, 1899, x, ]>. .5.5.

51 New York Med. Jour., 1899, Ixx, p. 1.58.

'-■-Journal of Experimental Medicine, 1898, Vol. iii, ji. 611.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

203

All measures failed except the packing of the nares both
anteriorly and posteriorly, which was finally resorted to.

It is the second case of ha'morrhagic typhoid we have had
here. When Dr. Hamburger reported the first case 685 cases
of typhoid had been treated in this hospital. This case makes
the second one out of a total of over 1000 cases of typhoid
which have been under treatment. Its rarity is also illus-
trated by Ouskow's statistics which gave four deaths from
ha^morrhagic diathesis ic G5l;^ cases of typhoid fever. Tlie
liaMiiorrhagic diathesis may manifest itself early in the typhoid
attack but more commonly it appears late in the disease.
It is rather a fatal complication but some cases do recover,
as did our first one.

Dr. Welch. — I think Dr. (Ipie's careful analysis of the re-
ported cases covers the ground coniidetely and brings up a
number of points of interest. I was especially interested in
four of the groups he specified, namely, the group in which
the lesions were so slight, as in his case, that they might be
readily overlooked; those in which the patient has died at a
time when one might readily suppose that the intestinal lesion
had healed; cases with only one or two ulcers, perhaps in an
uniisual situation, as in the vermiform appendix or the large

intestine; and the group in which there is a remarkable per-
sistence of the presence of the organisms after disappearance
of the intestinal lesions.

I think there is no question that cases of typhoid infection
can occur without ulceration of the intestines. Clinically
certain cases are so very mild that it is reasonable to think,
and tlie idea is not a new one, that there is no actual adcera-
tion, but merely an infiltration of the solitary follicles and
Peyer's patches. Then, the persistence of the typhoid bacil-
lus after recovery from the intestinal lesions is illustrated by
a number of observations. We have had instances here of
such persistence for months and indeed for years after recov-
ery from the disease. We know now that typhoid bacilli may
persist in the urine, even without any cystitis, long after the
patient is apparently well, and it is certain that they may re-
main a long time in the gall-bladder.

In the present case a less careful pathological study would
have led to its report as one entirely without intestinal
lesions, and it is quite proper, I think, that Dr. Opie should
express doubt, and indeed a certain degree of skepticism,
whether if this very minute study had been carried out in
all the cases there would not have* been found in some of
them some small lesion of the intestine.

FREQUENCY OF TYPHOID BACILLI IN THE BLOOD.^

By Rupus I. Cole, M. D.,
Assistant Physician, The Johns Hopl-ins Hospital. In Charge of Bacteriology.

Following the discovery of Bacillus typhosus by Eberth (1)
in 1880, numerous attempts were made to isolate the organism
from the patient's blood. Probaljly the first successful
attempt was that by Friinkel and Simmonds (2), who, in 188."),
reported one positive result in six cases. The same year
Wissokowitsch (3), Ijy animal experimentation, showed that
most bacteria, including IJacillus tyjihosus, when inoculated
into the circulating blood, unless in overwhelming numliers,
very quickly disappear from the lilood and find lodgment,
especially in the liver, spleen and bone-marrow. Following
this work repeated attempts to obtain the bacilli from Ihi'
blood were still made by many observers, some with long
series of cases, mostly with entirely negative results. These
observations in connection with the work of Wissokowitsch
led to the general acceptance of the view that the typhoid
bacillus entered the general circulation only very rarely and
tlicn very quickly disappeared. During the next ten years
quite a number of isolated cases of ty|ihoid septicannia were
reported in which the bacillus was isolated from the blood
either during life or at autopsy.

The first scries of cases in which the technique in obtaining
the cultures was good, and identification of the typhoid bacil-

' Read before the .Johns TTopkiiis ITospital Medical Society, February 4,
1901.

lus fairly certain (although agglutination was not tested),
was that of Kiihnau (4), who, in 1897, reported 41 cases, in
11 of which he obtained the typhoid bacillus from the blood
during life. He knew of the work of Stern (5) and others on
the germicidal properties of the blood, and, therefore, at once
diluted the blood in 50 ec. of bouillon, and from this at once
made plates, usually 20 in number. Other observers have
failed to find them in so considerable a proportion of cases,
so that only within the past few months, Scholz and Krause
(6), in an article on the clinical value of present bacterio-
logical methods in typhoid fever, after reviewing the work
on isolation of the bacillus from the stools, urine, rose-spots,
etc., state that cultures from the blood of typhoid patients
are of no value for diagnosis, since only in rare cases arc the
l)acilli found in the blood.

However, considering the wide distribution at autopsy, the
frequency of the bacilli in rose-spots, a.s shown during the
past two years by Neufeld (7), Curshmann (8) and Richard-
son (9) (in 32 out of 40 cases by the three observers), their
frequency in the urine (in about one-fourth of the cases, as
shown by Richardson (10), Gwyn (11), Horton-Smith (12)
and others, my own observations being 17 times in 49 cases),
and their having been found in lesions in almost every organ
and bone of the body, it has seemed probable that they must

204

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

be present, in some stage of the disease at least, not only in
the blood of the rose-spots, but in the general circulation as
well.

With a knowledge of the work of the previously mentioned
observers, I have, during the past few months, made a series
of cultures from the circulating blood of typhoid patients.
The technique briefly was as follows: The skin over the
anterior surface of the arm at the bend of the elbow was
carefully cleaned with green soap and water, followed by
alcohol, ether, bichloride of mercury (1-1000), and a hot com-
press soaked in the latter solution applied for from one-half
to one hour. It was found by experience that the hot com-
presses were of considerable importance in causing dilatation
of the superficial veins. When ready to take cultures, the
bichloride was removed by sponging with sterile water. In
a few cases the skin over one of the veins was incised and
vein dissected out before inserting needle. This is usually
a very unnecessary procedure, giving the patient a great deal
of pain and apparently increasing rather than decreasing the
chances for contamination. The only case in which my cul-
tures were contaminated was one in which this was done. By
thoroughly cleaning the -skin and hands of the operator and
by touching the needle only with sterile forceps, never with
the fingers, and by working with as little delay as possible,
all danger of contamination can be avoided. Just before in-
serting the needle the arm is grasped tightly below the
shoulder by a nurse or assistant and the needle is quickly
inserted into one of the superficial veins. By using a small
needle and entering the vein with one thrust there is no more
pain in obtaining 8-10 cc. of blood than in the administration
of a hypodermic or in the pimcture of the ear. In all cases
8-10 cc. of blood were withdrawn and, after removal of the
needle from the syringe, the blood was divided among a
number of tubes or flasks filled with bouillon. At first tubes
were used but in the last six cases, Erlenmeyer flasks, each
containing 150 cc. of bouillon, were used. One to six flasks
were used for each case, so that the dilution of the blood
was from 1-75 to 1-150. The flasks were then shaken and
placed in the incubator and after 24 hours, if cloudy, agar
plates were made. Usually the organisms in the bouillon
were somewhat clumped, at least sluggishly motile, and so not
suitable for trying serum reaction.

The diagnosis of Bacillus typhosus in each case was decided
by motility, staining properties, typical growth on agar, glu-
cose agar, gelatin, litmus milk, bouillon, Dunham's peptone
solution (which after one week's growth was used for indol
test) and finally, agglutination by known typhoid human
serum, dilution 1-50, in one hour. Frequently a fairly defi-
nite conclusion can be reached in 36 hours after obtaining the
culture. If the bacilli grow out in the bouillon in 24 hours,
they can be transferred at once to the various media, and
from the slant agar after 6-8 hours, a suspension in bouillon
can be made in which the serum reaction can be tried.

The table on opposite page gives a list of the cases from
which cultures were made with the results, and also the re-
sults of \irine cultures and Widal tests on the same cases.

Cultures were made from fifteen cases, in eleven of which
the typhoid bacillus was cultivated. From the last seven
cases in which a greater dilution of the blood was made, the
bacillus was obtained every time. The cases included both
those of moderate severity as well as those of great intensity.
i*'ive of the eleven cases in which the results were positive
subsequently died, so that apparently cultures were taken
from the more severe eases, though this was rather accidental
than intentional, as they were chosen at random. Three of
the cases in which the.organisms were isolated had very light
attacks. In one of the negative cases (VI) the cultures were
contaminated with air organisms. In this case the skin was
incised and vein dissected out. The child was not very ill
and was removed from the hospital before a second culture
could be taken. In one negative case (VII), in which cul-
tures were taken on two occasions, the course was prolonged
and of great severity. One of the other negative cases (VIII)
was also one of very great severity and cultures were taken on
tlivee difl'erent occasions with a negatfve result each time.
Tliis patient was pregnant and aborted on the twelfth day,
and the negative results are especially surprising and unfor-
tunate since Dr. Lynch succeeded in isolating the typhoid
bacillus from the blood of the foetus. This patient's urine
also contained typhoid bacilli. The organisms must have
been in the blood during at least a pai-t of the time and the
failure to grow is hard to understand. It may be mentioned
that this w'as one of the earlier cases and only bouillon tubes
were used in which to dihite the blood. In all of the eases,
with the exception of the two last mentioned, cultm-es were
made on but one occasion.

The positive results were obtained at various stages of the
disease, most of them during the second week, the earliest on
the sixth day, the latest on the twenty-seventh day, the latter
being on the second day of an intercurrent relapse.

In five eases (II, IX, XII, XIII, XIV) the cultures were
positive before a positive Widal test (dilution 1-50 in one
hour) was obtained. In one case (XI) the record of the date
of positive Widal test has been lost.

Cultures were made from the urine of twelve of the fifteen
cases and the liacilli were isolated from six, two of these,
however, at autopsy.

The cases were all clinically those of typhoid excepting two.

One of these (IX) was a ease which developed a continuous
temperature while in the hospital on the gynecological service
during convalescence from an operation for pelvic inflamma-
tory disease. The Widal reaction was positive 1-10, negative
1-50. The symptoms were those of intra-abdominal inflam-
mation, there was a possibility of intestinal tuberculosis, and,
while typhoid was suspected, the diagnosis was not at all
certain. Cultures were made from the blood twenty-four
hours before death and the ty]ihoid bacillus isolated — too late
however to make the diagnosis during life. The autopsy
showed typical intestinal lesions of typhoid.

The other (XIV) was a very acute case which entered the
hospital actively delirious, with some rigidity of tlie neck and
other signs of meningeal involvement, and with definite signs

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

205

TABLE.

1
Name.

BLOOD CULTURES. |

WIDAL TEST.l

UKINE

CDLTUEES.

Discharged
or died.

Medium.

Method.

Result.

Uesutt.

Day or
disease.

r.csuit.

KEMAKKS.

3 O

rt-a

at-a

6 Bouillon

Vein dissected out.

B. typhosus.

Positive.

Negative.

Discharged.

Prolonged course.

tubes.

Plates after 34 hrs.
Quite numerous
colonies on 4 plates,
2 negative.

Positive.

Intercurrent re-
lapse. Relapse.
Blood eultui-e on
second day of inter-
current relapse.

Ku.

(J Bouillon
tubes.

Agar plates from eacb
tube after 34 hrs.
Growth of a colo-
nies on one plate.
Others negative.

B. typhosus.

24
38
31

Negative.

Suggestive.

Positive.

Discharged.

Very prolonged
course. Never ex-
tremely ill.

III

Gr.

0 Bouillon
tubes.

After 34 hrs. all tubes
cloudy. Agar plates
from each tube.
Colonies on all
plates.

B. typhosus.

Positive.

Negative.

Discharged.

Rather prolonged
course.

Rh.

0 Bouillou
tubes.

Tubes clear after 34
hrs. Agar plates
from each tube. No
growth on any
plates.

No growth.

11
17

Negative.
Positive.

Negative.

Discharged.

Light attack. Never
very ill.

."> Bouillon

tubes.

After 34 hrs. 3 tubes
cloudy. Agar plates
from all tubes.
Colonies on plates
from 3 tubes.

B. typhosus.

Positive.

Death.

1.5

No complications.
No autopsy.

(i Bouillon
tubes.

Vein dissected out.
Culture obtained
with much dilliculty.

Contamina-
tion.

Positive.

Left the
hospital.

Patient not very ill.
Left before second
culture could be
made.

VII

Bu.

1.^

19
3.5

(J Bouillon
tubes.

6 Bouillon
tubes.

Agar plates after 34

hrs.
Agar plates after 34

hrs.

No growth.

Positive.

Negative.

Discharged.

6.5

Prolonged course
with relapse.

VIII

Br. 0.

9
15
23

8
8

7 Bouillou
tubes.

7 Bouillon
tubes.

Vein dissected out.
Skin not incised.
Skin not incised.

No growth.

U 11

Positive.

B. typhosus.

Discharged.

Severe case. Abor-
tion. See reference
iu text.

Bo.

0 Erlen-
meyer
tlasks of
bouillon

After 34 hrs. all
tlasks cloudy.
Agar plates from
all tlasks. Colonies
on all plates.

B. typhosus.

11
14

Suggestive.

Negative.

Died.

See reference in text.

McC.

1 Erlen-
meyer
tlask of
bouillon.

Agar plates after 34
hrs. Colonies on
all plates.

B. typhosus.

Positive.

Negative.

Died.

3.5

Severe case. Htcm-
orrhage, Pleurisy,
Perichondritis of
thyroid cartilage.

Br. M.

i Erlen-
meyer
tlasks of
bouillon.

Growth in one tlask.
Others negative.

B. typhosus.

Suggestive.

Dischai-ged.

Light attack.

XII

1 Erleu-
meyer
tlask of
bouillou.

Agar plates after 48
hrs.

B. typhosus.

6
14

Suggestive.
Positive.

Negative.

Discharged.

Attack of moderate
severity.

XIII

4 Erlen-
meyer
tlasks of
bouillou.

After 34 hrs. all
tlasks cloudy,
(irowth from all
tlasks.

B. typhosus.

Suggestive.
Positive.

B. typhosus.

Discharged.

4.5

Attack of moderate
severity.

XIV

III.

3 Erlen-
nieyer
llasks of
bouillon.

Growth in all llasks.

B. typhosus.

Negative.

autopsy.

B. typhosus.

Died.

See refei-eucc in text.

Ha.

3 Erlen-
raeyer-
tlasks of
bouillon
5 bouillon
tubes.

Growth in all tlasks
and tubes.

B. typhosus.

Positive.

At
autopsy.

B. typhosus.

Died.

Course rapid and
severe. No compli-
cations. Patient
lived but four days
after entrance to
hospital.

' By positive Widal test is meant complete agglutination iu oue hour with a dilution of 1-50, microscopical method.

20G

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 134.

in the chest of lobar pneumonia. The Widal test was entirely
negative. The history did not suggest ty])hoid, and, in the
presence of the lung signs, it was supposed to be only a case
of lobar pneumonia with marked cerebral symptoms. The
patient was admitted during the evening and on the following
morning spinal puncture was performed, the fluid obtained
being perfectly clear and free from organisms. At the same
time cultures were made from the blood. The following
morning in the cultures from the blood, instead of the pneii-
mococcus, a motile bacillus resembling the typhoid bacillus
was found, which subsequently was jirovcn to be that organ-
ism. The patient had died during the night, so that, while
the diagnosis was made by the blood culture, it had been
taken too late to make the diagnosis during life. The autopsy
showed, in addition to lobar pneumonia, well marked intes-
tinal lesions of typhoid fever.

In the Deutsche medicinische Wochensehrift, August 9,
1900, Schottmiiller, in a report of a case of fever caused by a
typhoid-like organism, states that in fifty cases of typhoid
fever from which he made cultures of the blond during life,
he was able to isolate the typhoid bacillus forty times. He
does not give the technique employed in the other cases, but
states that in the case reported he used solid media, using
large amounts of blood, fifteen to twenty ce. A full report
is to appear later.

Auerbach and linger in Deutsche medicinische Wochen-
sehrift of December 6, 1900, also report a series of ten cases
of typhoid in which cultures were made from the blood dur-
ing life, the typhoid bacillus being isolated from seven of
these cases. They also used fluid media and used quite small
amoimts of blood.

From all the results given, it is apparent that typhoid bacilli
occur in the blood with much greater frequency and during
a much longer time through the course of the disease than
was formerly supposed. The conditions which favor their
presence, why they are found at times in mild cases and arc
absent in more severe ones, are questions which miist yet be
solved. That cultures from the blood in typhoid fever have
very definite clinical importance, especially where the Widal
reaction is delayed, as is so often the case, is evident. From
my experience, the use of considerable amounts of blood,
diluting very largely in liquid media, and, on acioinit of the

use of the latter, especial care to avoid contaminations, are

the points of chief impurtance.

Eefekences.

1. Eberth: Virchow's Archives, Ixxxi-lxxxiii.

2. Friinkel u. Simmonds: Cent. f. klin. Medicin, 1885.

3. Wissokowitsch: Zeit. f. Hygiene, Bd. i (188G).

4. Kiihnau: Zeit. f. Hygiene, xxv (1897).

5. Stern: Zeit. f. Idin. Medicin, xviii (1890).

G. Scholz u. Krause: Zeit. f. klin. Medicin, xli (1900).

7. Neufeld: Zeit. f. Hygiene, xxx (1899).

8. Curshmaun: Miinchncr med. Woch., 1899, Nov. 38.

9. Eichardson: Fhil. Med. Journal, 1900, March 3.

10. Richardson: Journal Exp. Med., iii and iv (1898-99).

11. Gwyn: Phil. Med. Journal, 1900, March 3.

13. Horton-Sniith: Lancet, 1900, March and April.

13. Schottmiiller: Deutsche med. Woch., 1900, Aug. 9.

14. Auerbach u. linger: Deutsche med. Woch., 1900, Dec. 6.

Discussion.

Dr. Oslee. — One of the cases recorded illustrates, I think,
that this method will prove to be of considerable value; I do
not think that by any other means the diagnosis could have
been made on the young colored girl admitted at the end of
the first week with no rose-spots and nothing upon which to
base a diagnosis of typhoid fever. The one thing evident
was, that she had a violent, acute infection of some kind.
The cultures made on the morning of admission would have
given us the diagnosis positively within 24 hours, but un-
fortunately, in this case, the patient succumbed to the disease
the same day. The earliest date in which bacilli were found
was the 6tli day of the disease. The number of bacilli, how-
ever, could not be determined.

De. Welch. — That is a misfortune of the method. The
statement has been made that the Widal reaction is most
likely to be absent when there are many bacteria in the blood.
It has been contended by some that there is an antagonism
between a large number of bacilli circulating in the blood
and the Widal reaction.

De. Cole. — In six of the cultures the bacilli were foimd in
the blood before the Widal reaction was present.

A POKTABLE OPERATING OUTFIT.

V.Y J M. T. Finney, M. D.,
Associate Professor uf Sur(jcry in the Johns Hophins Medical School,

AND

Omar Pancoast, M. D.

Every surgeon who has been compelled to operate often in
private houses, sometimes several hundred miles from any
large hospital, appreciates fully the difficulties of the problem:

how shall we manage to preserve a careful technique and
approach the methods of a hospital operating room without
too great expense, delay and inconvenience? In order to

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

207

remind the general praetitioner of some of tlie chief diftieiil-
ties, it may be well to mention some of the many sources ol'
delay and vexation.

Fig. 1.

flights of stairs away; of two smaller tables placed together,
frequently of uneven heights and much too broad; or of an
ironing board placed insecurely on the backs of chairs or on
small tables. All of these things may have to be brought
from distant parts of the house and are frequently needed for
other purposes, such as to hold supplies, basins, etc. Another
frequent difficulty is an insufficient supply of clean basins to
contain the various solutions necessary for hand disinfection,
instruments, etc. It may become necessary to borrow from
the neighl)ors and often to waste considerable time in render-
ing them fit for -surgical use.

For a long time we have been in the habit of always taking
a trunk with us to carry the necessary supplies and basins,
bnt as the basins in regular hospital use are not generally of
such sizes as to be easily and closely packed, we have often

Fig.

The surgeon of course carries with him a supply of instru-
ments, dressings, materials for anesthetizing the patient and
for preparing the field of operation. Sometimes these are
carried in a trunk, sometimes in a hand-bag or telescope-
satchel or in several such satchels.

On ai-riving at the house of the patient usually one first
endeavors to procure something that will do service as an
operating table. For any major operation the table should
answer the following requirements: It should be sufficiently
strong; it should be sufficiently high, so that one should not
be compelled to stoop; it should be so narrow that the oper-
ator and assistant may stand on opposite sides and work in a
comfortable unstrained position.

As a rule, one finds himself compelled to make use, either
of the kitchen table, broad and low and perhaps several

considered the advisability of obtaining a complete set of
basins for outside work and then having a trunk made to
contain them, the instrument kettle and various necessary
supplies, all in sepai'ate compartments to prevent shifting
when the trunk is roughly handled.

In the trunk we present to-night we have accomplished
these purposes and in addition have been able to add three
very useful features. We have had the trunk so constructed
that it can be readily converted into a very satisfactory table;
we have had the tray so made that it forms a perfectly suitable
table for instruments or basins; and we have also had made a
skeleton Trendelenburg which when extended and covered
with canvas may be placed on the trunk-table, converting it
into a Trendelenburg operating table. We have accomplished
these purposes by having the depth of the trunk increased

208

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 134.

but two inches beyond that required for the ordinary sup-
plies. The exact methods by which we obtain these results
are made clear by the accompanying illustrations.

A few words perhaps are necessary to explain our method
of using this outfit.

bichloride solution and the smallest of tliis set is sterilized
by soaking in the same manner. The large basin is finally
used for the operator's hand-basin of bichloride and the small
one for sterile water, salt solution or sponges as the occasion
requires. Two of the round basins are used for the saturated

Fig. 3.

Fig. 4.

The large arm basin containing four or five instrument
trays is immediately filled with a 1-1000 solution of bichlor-
ide of mercury and the trays are thus sterilized by soaking.
When taken out each may be covered with a sterile towel or
tray cover. The largest of the round basins is filled with

solutions of permanganate of potash and oxalic acid. The
remaining one is for the soap and water used in shaving and
cleaning the site of operation. The instruments are carried
packed in the kettle and so may be boiled at once.

In order to form a rigid table the trunk when open is

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

209

securely fastened in this position by a thumb screw, as shown
in the figure. The legs after insertion may be clasped very
tightly by a few turns of the screw which regulates the size
of the opening in the corner castings.

The table is usually covered with a folded blanket, mackin-
tosh, sheet, and a Kelly or Morrison pad which drains into
a bucket on the floor. When the Trendelenburg is used the
trunk is protected by a mackintosh alone, while a pillow is
placed over the cross rod of the Trendelenl)urg to protect
the patient's head and shoulders.

The various chemicals necessary are carried in ordinary
mailing cases so as to avoid the danger of breakage when
glass bottles are carried. We use the wooden cases with
screw top after carefully washing them and removing the
wadding and paraffin. Sterile concentrated salt solution,
cocaine, etc., are carried in bottles in mailing cases and are
previously sterilized by the following process: A cork is put
lightly in the bottle containing the solution and the whole top
of the bottle and cork are then covered with an absorbent-
cotton shield fastened around the neck of the bottle. After

sterilization the cork is pushed home through the cotton and
the solution remains sterile indefinitely.

In conclusion we beg to express the hope that this trunk
may be of service to other surgeons and be one means of intro-
ducing a more perfect technique in " outside " operations.

FINNEY-PANCOAST OPERATING TRUNK.
Dimensions of Trunk closed, 3.5" long, 18%" wide, 153^" higli.

as table, 70'
Tray " " Sl)^" '

10%'

35"
34"

Trendelenburg. Length closed, 31"
" " open, 41>^"

Width, 17"

Height of Elevation, 21"

Weight of Trunk with Tray, OOJ^ lbs.
" " Trendelenburi; with Canvas, l:i'^ lbs.
" Tray, '.)« lbs.

" " Legs for Trunk, S}{ \hs.. } .„

" Tray, 4)^ lbs. f

( Full set of Basins, ■>
" " J Instrument Trays, J. 27 lbs.

( Boiler, &c. j

" " Rubber Sheeting, 2}{ lbs.

Gross weight of Trunk and contents, 115^ lbs.

lbs.

ULCER OF THE STOMACH CAUSED BY THE DIPHTHERIA BACILLUS.

By William E. Stokes, M. D.

Although the diphtheria bacillus has been known as the
cause of various inflammations of the respiratory tract for
some little time, yet it has but recently been described in
connection with such atypical conditions as diphtheritic in-
flammation of the conjunctiva and the external auditory
meatus. Diphtheritic infection of wounds of the skin and
diphtheritic vulvo-vaginitis have also been observed, but
these rare infections are all completely described in " Osier's
Practice of Medicine," or in Baginsky's article on Dijjhtheria
in " Nothnagel's Specielle Pathologic and Therapie."

Schoedel (1) has recently reported a case of fibrinous inflam-
mation of the gastric mucous membrane, due to the diph-
theria bacillus, and as I have also found a gastric ulcer caused
by this organism at the autopsy in a case of proven tonsillar
diphtheria, I shall first refer to Schoedel's (1) article some-
what in detail.

This writer first reviews the literature, mentioning the fact
that Klebs (2) and Loelfler (3) have both described cases oC
gastric diphtheria, in which they demonstrated their bacilli in
stained sections. Wright (1) also found diplitheria bacilli in
the stomach in two out of fourteen autopsies on diphtheria.

Schoedel's case was that of a child who died of faucial
diphtheria without any gastric symptoms. The uvula con-
tained a grayish membrane, but the esophagus was normal.
Tlie mucous membrane of the stomach was very red and
covered here and there with a gray adherent membrane. The
lymphatic structures of the intestine were swollen. A culture

' Read before the Johns Hoiikins Medical Society, January 91, 1!I01.

from the membrane made on Loefiler's blood serum showed
a large number of typical diphtheria bacilli, and these were
also demonstrated in stained sections. This writer also found
virulent diphtheria bacilli in the stomach of two children,
dead from diphtheria, and in one of eight cases he was able
to demonstrate the bacillus in cultures from the feces by
means of its typical bipolar stain.

Schoedel thinks that the acid gastric juice can usually de-
stroy a small number of diphtheria bacilli when they are
swallowed, and that primary diphtheria of the stomach is
thus well nigh impossible. In cases of widespread diphtheria,
however, when the gastric acid is lessened in amount, large
numbers of diplitheria bacilli are apt to bring about some
local lesion of the mucous membrane of the stomach, when
once swallowed. Although these cases are not usually de-
tected at the bedside, their existence should not be lost sight
of by the clinician.

The case which I desire to descrilie occurred in November,
1900, and as the young man was picked up off the streets sut-
fering from well-marked diphtheria and housed in a vacant
room in the Health Department, the clinical history is neces-
sarily meager. All that could be obtained, however, was
recorded, and I am indebted to Dr. C. Ilampson Jones, Assist-
ant Commissioner of Health, for his clinical report upon the
case.

Clinical Report.

The patient was found on the streets and was referred to
the Department of llealth for treatment, owing to the fact
that there is no infectious hosiiilal in the city.

210

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

Cultures taken from the throat on two scjiarate occasions
showed the presence of diphtheria bacilli. A cot was provided
for the patient in a vacant room and a nurse was placed on
duty.

The fever remained high for several days, and the mem-
brane gradually disappeared from the tonsils, as the patient
received 10,000 units of antitoxin in about four days. About
the sixth day of treatment, and when the membrane had
almost disappeared from the throat, the temperature fell, and
even became subnormal. The patient also complained of
pain and liyperajsthesia in the epigastric region, and died
about ten days after being admitted for treatment at the
Health Department. It was impossible to find out how long
the patient had suffered from diphtheria liefore he was seen
at the Health Office.

Kepoet upon Autopsy.

The autop.sy was performed by Prof. N. G. Keirle, Medical
Examiner, who has kindly allowed me to use his notes.

Post-mortem held at the morgue on November IS, 1900.
R — S — . Age twenty-iliree years. Ante-mortem statement.
History of epilepsy. Autopsy record. Inspection. Yellow
pseudo-membrane on fauces, velum and right tonsil.

Brain. — Hyperemia and edema. Pia thickened aiul ail-
herent to corpus callosum, which it tears on removal.

Lungs. — Hyperemic. They ooze freely a frothy blood-
stained serum. The lower lobe of the right lung is solidilii'd.
This solidification was not exactly that of lobar pneumonia.
but consisted of large solidified areas, separated l>y a looser
edematous tissue in places almost normal in appearance. Tlu^
pleru'a was smootli.

Heart. — Normal. Hemoglobin staining of the intinia of
the aorta and pulmonary arteries.

Liver. — Fatty, and kidneys coarse, thick and yellow.

Cortex shows cloudy swelling.

Slomnrli. — This shows an ulcer two and a half cm. by one
cm. near the pylorus in the most dependent portion of the
greater curvature of the stomach. It is covered with a dark
yellow membrane, in places almost black. The surface is
necrotic beneath. The rest of the mucous membrane of the
stomach was normal in appearance, and the intestines were
also normal.

Cause of Death. — Septicemia of diplithorilic origin.

Histologic Description.

Before describing the interesting changes which were found
in the stomach, a brief report upon tlie changes in the various
other tissues and viscera will be given.

The Ilight Tonsil. — The right tonsil when stained by
hematoxylin and ecsin shows a well-marked dilatation and
congestion of the numerous blood spaces present throughout
the organ. These are packed full of red blood corpuscles.
and are often dilated to the size of a small vein. They are
very numerous, and are usually simply surrounded by a single
layer of endothelial cells. The normal stratified epithelium
has disappeared over a large portion of the surface of the

tonsil, and this loss of substance ends rather abruptly at one
side of the section in normal epithelium. The epithelial
cells are simply replaced by a thin band of connective tissue
containing many round, oval or spindle-shaped newly formed
connective-tissue cells. There are few, if any, pus cells and
no fibrin present, and beneath this newly formed tissue the
lymphoid masses of the normal tonsil can be seen. The entire
appearance is that of healing inflammation of the surface of
the tonsil.

On staining tlie tonsil by Weigert's bacterial stain a mod-
crate number of foci of bacteria can be demonstrated on the
surface. These consist both of bacilli and cocci. These cocci
probably are the staphylococcus pyogenes aureus, and they
must have entered the circulation from this area, as a few
colonies of a similar organism were found in the spleen and
blood of the heart by cultures on blood serum. The bacilli
are specimens of diphtheria bacilli, as demonstrated liy cul-
tures. Stained sections of the other tonsil showed nothing

of interest. ,-, „

Other Viscera.

There is a well-marked, cloudy swelling of the liver present,
but no other changes are noted in this organ. The kidney
shows pronounced congestion of the capillaries, both between
the tubules and in the glomeruli of the capillaries, and a feu-
hyaline and granular casts are present in the tubules. The
sj^leen sliows slight congestion, and the splenic spaces are
distended liy proliferated endolheJial cells. The heart muscle
and lirain show iiolliing unusual. No bacteria eould be
stained in any of these organs.

Lungs.

Sections taken friun the more solid areas mentioned in con-
nection with the lung showed the following condition:

The small blood-vessels and veins .show well-marked con-
gestion, and the air cells are usually filled with an edematous
fluid often containing many pus cells. In some areas the pus
cells entirely fill up the air sacs, causing an appearance similar
to that seen in the stage of gray hepatization in lobar pneu-
monia. The bronchi are normal, and there is no fibrin pres-
ent. In specimens stained by Weigert's method a moderate
number of diphtheria bacilli can be seen both in the edema-
tous fluid, and in the more densely packed masses of pus cells.
Some of these bacilli are within the protopla.sm of the neutro-
philic leucocytes. There are also present a large number of
short chains of streptococci, which were not detected in the
cultures from the lung.

Illustration Showing a Section made through the
Edge of the G.\stric Ulcer:

The rest of the ulcer shows about the same changes, and
its surface consists entirely of necrotic tissue. This tissue
contains numerous diphtheria bacilli. The ulceration has
only extended as far as the muscular coat, where regeneration
has already begun. The hyaline degeneration of the sub-
mucous coat and the eroded lilood-vcssel are well shown in
the illustration, which also sliows the necrotie tissue, and the
overhanging mucous membrane.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

211

b i^^-LTe /vo /.

A. Peritoncil Coat.

B. Muscular Coat.

C. Submucous coat, showini;; superficial necrosis, liyaline de!;:eneration,

and regeueratioii of tlie base of tbe ulcer.

D. Layer of fibroblasts at the base of tlic ulcer.

E. H}-aline degeueration of the submucous coat.

F. Liiyer of polymorphonuclear leucocytes invading the necrotic

area.

G. Superficial Layer of coagulation necrosis which contains many

diphtheria bacilli.
H. ITcmorrhagic area in the submucous coat.

I. Musouhiris raucosie ending abruptly at the margin of the ulcer.
K. Mucous coat ending abruptly at the margin of the ulcer.
L. Artery of submucous coat showing hyaline necrosis of the walls and

infiltration with leucocytes.
XI. Peptic glands in the mucous membrane.

212

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

Stomach.

The ulcer of the stomach mentioned in the account of the
autopsy consists of an extensive mass of coagulative necrosis,
which has entirely replaced the mucous membrane. This
necrotic area extends well down into the submucosa, and
laterally it has undermined the mucous membrane. This
overhangs the necrotic area on either side. Beyond the
necrotic material, and limiting the extension of the lesion in
the submucosa on either side of the ulcer, the tissue has un-
dergone hyaline degeneration, only a few strips of connective
tissue having still retained their nuclei. Portions of this
hyaline tissue are dotted with small irregular hemorrhages.
This thin strip of hyaline degeneration and hemorrhage ex-
tends from the sides to the bottom of the ulcer, forming its
base, and separating the ulcer from the normal muscular coat
beneath. That portion of the base just adjacent to the noi'-
mal muscle is richly infiltrated with newly formed connective-
tissue cells of various sizes and shapes, indicating the begin-
ning of regeneration at the base of the ulcer. The base of
the coagulative necrosis in the ulcer contains a moderate
number of pus cells. On applying Weigert's fibrin stain no
fibrin could be demonstrated in the sections.

Bacterial Stains.

When the sections of the ulcer are stained for bacteria by
Weigert's method, a remarkable appearance is presented. It
might be remarked in passing that these sections were first
stained by hematoxylin and then by eosin, according to the
usual method, and after washing out the excess of eosin in
water the sections are mounted on a slide and stained witli
gentian violet. The other well-known manipulations of
Weigert's bacterial stain are then applied and the section is
mounted in balsam. This triple stain differentiates all of
the histological features in a satisfactory manner, while the
bacteria which stain by Gram's method are clearly shown.

The diphtheria bacilli in the stained sections are limited to
the necrotic material, and are more numerous on the surface
of the nicer. They are irregularly distributed throughout
tlie entire area of necrosis, but are so densely packed together
in a meshwork on the surface as to render individual inspec-
tion of bacilli impossible. Many of these organisms are very
long, and some are spiral shaped. They are about tlie widtli
of the diphtheria bacillus, however, and may be long forms.
Most of the bacilli present the usual appearance of diphtheria
bacilli in cultures, but there are some rather large square-
ended organisms about the size of an anthrax bacillus, whicli
may be unknown organisms whicli failed to grow in the cul-
t\ire from the ulcer. Even under the low power of the
microscope the masses of bacilli are quite apparent on the
surface, as homogeneous, or scattered blue foci. On examin-
ing the border of contact between the necrosis and the thin
line of pns cells, the abrupt ending of tlie bacilli just at the
line of contact with the neutrophilic leucocytes might well
answer to the fanciful description of two armies just about to
engage in a battle.

Just a few bacilli can be found on the extreme edge of the
line of pus cells, and only here and there can one be found
within the protoplasm of the leucocytes.

Bactesiological Examination.

The bacillus isolated from the right tonsil was subjected to
the following tests:

A coverslip from a pure culture on blood scrum was stained
by Loeffler's methylene-blue, and the bipolar, or interrupted
staining, was very apparent. A pure culture was ol)tained,
and inoculated into 1 per cent lactose bouillon. This was
acidulated in 24 hours. Gelatin was not liquefied, and the
organism was not motile.

Cultures from the ulcer of the stomach and the lungs
also contained numerous diphtheria bacilli. The liver
and kidney contained many colon bacilli, and the spleen
and the heart showed a few colonies of staphylococcus pyo-
genes aureus.

One cubic centimeter of a 24-hour bouillon culture of the
bacillus isolated from the ulcer of the stomach was injected
subcutaneously into the abdominal tissues of a guinea-pig.
The animal died in 6 days, and the seat of inoculation showed
a gray necrotic area the size of a dime. Under the micro-
scope this area consisted of a mass of polymorphonuclear leu-
cocytes which not only formed a thick layer on the surface of
the muscle, but which have also infiltrated the abdominal
muscle, forming collections of cells lietween the muscle bands
and fibres. On staining this tissue by Weigert's method
numerous diphtheria bacilli can be demonstrated. Many of
these show large club-shaped ends, and in a few the bipolar
stain can be seen. Cultures made on blood serum from this
area gave a pure growth of the diphtheria bacillus. The
lungs showed marked active congestion, but the air cells were
free from any exudate. The rest of the viscera were normal.

Summary.

It is a point of some interest to note that the stomach is
not always able to destroy large numbers of diphtheria bacilli,
especially when the powers of resistance have been lessened
by an acute disease.

The ulcer which was found was certainly produced by the
diphtheria bacillus, and it may ajipear later that these stom-
ach lesions are not as rare as was f ormerl thought.

In conclusion I desire to thank Prof. N. G. Keirle for his
kindness in allowing me to use his autopsy material.

Literature.

1. Miincli. med. Woclicnschr., June Sfi, 1900.

2. Verhandlnng des II Congress f. inner. Med., 1SS;1.

3. Central, f. P.ak., 1887, Bd. II, No. 4.

4. Boston Med. and Sur. .Journal, October, 1894.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

213

OVARIAN ORGANOTHERAPY.

By William Krusex, M. D., Philadelphia, Pa.

The organs, tissues, aud secretions of animals were exten-
sively employed as therapeutic agents by the ancients, and
constituted a prominent pai-t of their disgusting and nauseat-
ing medicinal armamentarium. Pliny informs us that the
ancient Greeks and Romans ate the testicles of the ass for
the purpose of curing impotence, forestalling the later inves-
tigations of Brown-Sequard by hundreds of years. In 185;i,
Dr. Jackson of Philadelphia made a definite attempt to apply
animal tissues to the cure of disease by administering the
blood of bullocks carefully dried in vacuo, in five to ten grain
doses, as a tonic. The use of glandular extracts was revived
in 1889 by Brown-Sequard's advocacy of orchitic extract for
impotence and ceitain nervous att'ections; and the interest
was profoundly stimulated by the results which Prof. Geo. R.
Murray, of the University of Durham, in 1891, obtained Ijy
the use of thyroid extract for the cure of myxedema. Since
that period medical literature has been flooded with a deluge
of reports of all kinds of extracts. Cerebrine, niedulline,
cardine, and many others too numerous to mention, have
been presented to the profession, tried in the balance of
practical experience and found wofuUy wanting. One would
not be surprised to find some enterprising and energetic drug
firm vaunting the merits of musculine for pugilists and
athletes, or advising political spellbinders to imbibe eloquence
and gloso-labial extracts at the same draught.

The popularity of this line of medication depends upon the
theory of Brown-Sequard, that all glands, whether provided
or not with excretory ducts, have the power to ela)_)orate, in
addition to their ordinary secretions, certain materials of
unknown chemical composition, which pass into the blood
and }>erform therein definite functions of some kind. Tlie
efficiency of thyroid extract in the treatment of my.xedema
and cretinism has substantiated the theory to a certain extent,
but the limitations of its application remain to be determined.
The animal extriets which have a particular interest for
gynecologists are the uterine, mammary, parotid, thyroid, and
ovarian; and of the last of these and its value it is my purpose
to speak, hoping to elicit a discussion which may prove val-
uable to profession and patient.

In studying the action and uses of ovarian extract it is
interesting to review the conclusions of Curatulo in regard
to the internal secretion of the ovary. 1. The ablation of
the ovaries exercises a considerable influence on metabolism.
2. The quantity of phosphates eliminated ])y the urine is
notably diminished after the removal of the ovaries. In real-
ity, this diminution is not due to elimination, which is the
same before and after the operation, or to the diminution of
the absorbent power of the intestine; for the condition in
which the gastro-intestinal tract is found is the same before

' Read before the Johns Hopkins .Medical Society, February 4, 1901.

as after the operation. 3. The curve of nitrogen, after ova-
riotomy, ascertained either by Kjeldahl's method or by
Yvon's, presents a slight oscillation, without a very distinct
tendency to elevation or lowering. 4. After oophorectomy
the quantity of carbonic acid elhninated by the respiration,
and that of the oxygen absorbed, diminish considerably up
to a certain limit, from which time it remains stationary.
•J. In animals from which the ovaries have been removed, the
curve of the weight is progressively elevated until it attains
considerable proportions from 5 to 6 months after the oper-
ation. G. When a certain amount of ovarian juice is injected
subcutaneously into sluts deprived of the ovaries, the quan-
tity of phosphates eliminated by the urine, which diminished
considerably soon after the operation, tends to increase and
even to become superior to that which was ascertained before
the operation; when still larger amounts are injected the
quantity of phosphates increases in a very marked degree.

Hysterectomy performed in conjunction with oophorec-
tomy does not seem to cause modifications other than those
ascertained after simple removal of the ovaries. The author
closes his essay with the following tlieory: The ovaries, like
other glands of the animal economy, have, according to
Brown-Sequard's general doctrine, a special internal secre-
tion. These glands continually throw into the blood a pecu-
liar product, the chemical composition of which is completely
unknown, and the essential properties of which tend to favor
the oxidation of phosphorized organic substances, of carbo-
hydrates, and of fatty substances.

It results therefrom that, when the function of the ovaries
is suppressed, whether because oophorectomy has been prac-
ticed or because the organs do not act, as is the case before
puberty and after the menopause, there should be produced,
on the one hand, a more considerable retention of organic
phosphorus, whence there is a greater accumulation of cal-
careous salts in the bones; and, on the other hand, the very
manifest corpulency which is ordinarily seen after oophorec-
tomy or after the menopause.

This probably suggested the value of substitution therapy,
the restoration to the diseased body of chemical substances
the removal of which from the normal body gives rise to
symptoms of disease. It is not necessary to review the various
psychic or vasomotor disturbances which are as.sociated with
the natural and the premature menopause; they are too well
known to need further comment.

W^erth of Kiel was the first who made use of the ovarian
treatment in troubles which accompanied the disappearance
of the secretion of the ovary following either the menopause
or surgical intervention. Out of ten cases, in two only did
the treatment fail to bring aljout any result; in the other
eight there was a diminution of general pains, of the head-
ache, of the loss of appetite and sleep, of the palpitation and

'2U

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

of the feeling of anguish. Mainzer of Berlin obtained a con-
siderable amelioration of the symptoms following double ovar-
iotomy by administering to his patients the raw ovarian
substance of the cow or the calf, in daily amounts of from
T5 to 150 grains. It has been demonstrated that such large
doses are not necessary. Mond has used it successfully in
disorders of the natural menopause and in amenorrhea due
to atrophy of the genital organs, or to neurasthenia. Spill-
man and Etienne also obtained good results in chlorosis from
the administration of the fresh ovaries of sheep, of the dried
ovarian substance, and of the ovarian juice. According to
these authors, this treatment acted by facilitating the elimi-
nation of the toxines, increasing the red globules and causing
the reappearance of menstruation. Mairet, Jayle, Touvenaint
and Jouin have published observations in which this medica-
tion has led to favorable results in the treatment of amenor-
rhea and chloroanemia. Guerder and Vigier have found the
symptoms of the natural menopause were relieved. The
latter, after freeing the ovarian substance from foreign matter
as fat, fibres, etc., mixed it with bicarbonate and charcoal,
which preserves it indefinitely without interfering with its
therapeutic effects.

Bodon (Centralblatt fiir Gyuakologie, August, 1897) re-
jjorts three cases in which he employed ovarian tablets with
good ett'eet. The third was that of a virgin, 18 years old,
who had suti'ered with epilepsy since her tirst menstruation
and had been under treatment for years. Bromides and other
drugs had proved utterly futile. She began with one tablet
daily and increased the number to ten. In the course of
several months the epileptic attacks ceased; but discontinu-
ance of the drug was followed by fresh seizures and its re-
sumption again caused their subsidence.

Jacobs (Semaine Gynecologique, June 22, 1897), although
skeptical at the beginning of his observations, had confidence
in the remedy to continue its use. The extract of the ovaries
of recently killed animals was used and he has tabulated 81
eases, of which only 5 are classed as failures. In one case
of obesity with amenorrhea of 19 years standing, the obesity
diminished and menstruation became regular. Another
patient, 21 years of age, with undeveloped genitals, had never
menstruated; but after taking ovarian extract for a month,
menstruation appeared and has continued regularly ever
since. Jacobs believes that suggestion plays a prominent
part in some of these eases, though not in all. Landau
(Berlin, klin. Woch., No. 35, 1896) believes that this remedy
does possess the power of modifying the unpleasant phe-
nomena of the climacteric whether physiologic or anticipated,
without producing any evil effects, and that it deserves care-
ful consideration.

Chrobak (Cent, fiir Gynak., No. 20, 1896) administered
ovarian extract made from the fresh ovaries of cows, to a
number of castrated women and had good results in two cases
reported. Fosburg (British Med. Jour., April 24, 1897) gives
the history of a patient who at the climacteric was much
troubled with frequent and violent flushing, the face often
being in a burning heat while the hands and body were icy

cold. Five grain platinoids of ovarian gland, administered 3
times daily, gave complete relief before 3 dozen were taken;
and one platinoid given occasionally prevented recurrence.

Seeligman (Allg. Med. Centralzeitung, No. 3, 1898) reports
15 cases treated with extract of the ovaries of sheep and pigs,
and ■concludes that the remedy has a decidedly beneficial
effect, not only upon typical climacteric phenomena, but also
upon the psychic condition and upon constitutional diseases
such as gout, psoriasis, etc., which after long remaining latent
develop at the menopause. Bate (Louisville Journal of Sur-
gery, vol. V, 1898-99, p. 11) states that "• physiologic action
of ovarian extract as now observed is vaso-constrictor, nerve
sedative, emmenagogue, and anti-anemic"; a combination of
qualities which, if it tridy possessed them, would make it a
most valuable acquisition to our pharmacopeia.

Stimulated by such enthusiastic and gratifying clinical re-
ports 1 began the use of ovarian extract, employing capsules
prepared by a reliable firm, since the ingestion of raw ovaries
or nauseous doses is not usually appreciated by the average
American woman. For the past three years, in selected cases,
in dispensary and private practice, the effort has been made
to obtain some definite result from the use of this carefully
prepared ovarian extract, in 3 classes of cases: (1) Those
suffering from amenorrhea, dysmenorrhea and other forms
of pelvic disease; (2) those suffering from symptoms following
the removal of the uterine appendages, for the relief of the
vasomotor changes, the flushes and cardiac neuroses which,
with indescribable depression, are so often produced by the
premature menopause; (3) the disturbances associated with
the natural menopause. My first case was that of an intensely
neurotic patient suffering from artificial menopause. Marked
relief was noted for a Ijrief period; then there was a recurrence
of the symptoms. Later the patient became an adherent of
Christian Science and has obtained more relief from auto-
suggestion than from inspissated ovaries. Many other dis-
appointing instances were met with. Patient after patient
would faithfully take the extract to the exclusion of other
remedies without any perceptible result, although occasionally
the effect would be apparently so marked and the results so
satisfactory as to encourage its further use. For instance,
such a history as the following, taken from the case-book at
St. Joseph's Hospital, would incite to renewed confidence in
the efficacy of the preparation. Jan. 9, 1901, Mrs. A. C aged
26 years, had had double ovariotomy performed by Dr. Joseph
Price; general condition good, pelvic examination negative,
but complained of hot flushes every few minutes and extreme
nervousness. Five grain capsules of ovarian extract, 4 times
daily, were ordered. The patient returned in 3 days stating
that the nervousness was better and the hot flushes decreasing
in frequency. In one week the nervousness had disappeared
and hot flushes occurred only on exertion, two or three times
daily. Another case in point was that of Mrs. J. W., patient
of Dr. Chas. B. Smith of Newtown, Pa., who was operated
upon for double pyosalpinx. Within 2 months after leaving
the hospital she began with the usual vasomotor phenomena
and relief was secured by the administration of 5-grain doses

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

215

of ovarian extract 3 times daily. Time and a regard for your
patience prevent my giving a detailed history of more cases;
besides the recital of our failures is never pleasant; yet it
seems unfortunate that more of those who have been disap-
pointed in their use of this product have not given their
experience; only a few seem to have done so. Montgomery
(International Med. Mag., Nov., 1900) states that he has
never seen the slightest influence from the use of ovarian
extract although he has found the thyroid especially valuable
in the treatment of cases of myxedema, obesity, and in some
forms of sterility; and Baldy says that " a careful considera-
tion of this subject forces one to the conclusion that it is
destined quickly to follow in the steps of the testiciilar injec-
tions urged several years ago with the object of renewing
youtli." Johnstone of Cincinnati may give the correct ex-
planation of the failure to secure more definite and satisfac-
tory results from the use of ovarine. He says: " There is
not an iota of proof that the ovary has any other function
than the manufacture of eggs. The ovary is in no sense a
gland. Its epithelium is arranged for the purpose of being
east out and lost, and is not placed so that its secretions, if it
has any, could be absorbed cither by ducts or blood-vessels.
Anatomically, the ovary does not resemble the suprarenal,
the thymus, or the thyroid gland. The thymus is a lymphatic
gland, the thyroid and the suprarenal have a rich supply of
blood-vessels so arranged that each epithelial cell is closely
approximated to a venous radical, thus providing for a rapid
absorption of whatever secretion its cells may malce. The
ovary has a true duct, through which its epitlielium, when
cast out, passes off en masse to the outer world."

Probably Jacobs struck the keynote when lie said that
"suggestion plays a prominent part in some of these cases'";
for this might explain why we have successes and failures
under tlie same conditions without apparent cause. Not-

withstanding the many brilliant results referred to in this
paper, experience leads me to the following conclusions based
upon the use of the American product upon American women:
(1) The employment of ovarian extract is practically harm-
less, as no untoward effects beyond slight nausea have been
noted even when full doses have been administered. (3) In
the treatment of amenorrhea and dysmenorrhea no good
results were secured. (Although in some cases of amenorrhea
of obesity, remarkable results have been obtained by the use
of the thjToid extract.) (3) The best results were seen in
the second class of cases, for the relief of symptoms of arti-
ficial menopause, when in a few instances the congestive and
nervous symptoms were api^arently ameliorated. (4) No ap-
preciable result was noticed in the use of ovarine in the nat-
ural menopause. (5) No definite or exact reliance can be
placed upon the drug, as it often proves absolutely valueless
where most positively indicated. (6) It is extremely proble-
matic whether, in those cases in which relief was noted, the
effect was not due to mental suggestion rather than to any
physiologic action of the drug. The neiu'otic type of indi-
vidiial demanding this treatment will often be relieved by
any simple remedy. (7) In those instances in which effects
were noted increase in dosage seemed to have little influence
in maintaining the efl'ect or preventing the patient from
becoming accustomed to its use. (8) In conclusion, the
theory which suggests the use of this extract seems to be at
fault, and the administration of ovarine or ovarian extract is
based upon a wrong assumption as to the function of the
ovary. In organotherapy, the best results have been obtained
from the use of the thyroid and adrenal glands, and the, ovary
in function is in no sense analogous to these organs. Its
princiiial function is ovulation, and if any peculiar product
is eoincidently manvLfactured, the isolation of this product has
not yet been accomplished.

JESSE WILLIAM LAZEAE MEMORIAL.

On the 25th of September, 1900, Jesse William Lazear, at^
tliat time Acting-Assistant Surgeon in the United States
Army and a member of the Government Commission for the
investigation of yellow fever, lost his life from that disease
at Quemados, Cuba.

Doctor Lazear was born in Baltimore County, Maryland, in
18G6, and graduated from the academic department of the
Jolms Hopkins University in 1889. In 1893 he received the
degree of M. D. from Columbia University. From 1892-95
he spent his time in study and investigation in Europe and
as an interne at the Johns Hopkins Hospital in Baltimore.
During the following three years and a half, while a member
of the staff of the Out-Patient Department of the Johns
Hopkins Hospital, he did much valiiable work as a teacher
and investigator in the laboratory of clinical pnthology. In
February, 1900, induced by the opportunity for research con-
cerning malarial and yellow fevers, Lazoar Ijecamc an acting

assistant surgeon in tlie United States Army and was assigned
special laboratory duties at Columbia Barracks, near Ha-
vana. Later, ho was appointed member of a special gov-
ernment commission for the investigation of yellow fever.
The brilliant discoveries of this commission concerning the
ffitiology and manner of infection of yellow fever have re-
cently been referred to in public by a distinguished patholo-
gist as the most important piece of work by American
students since the discovery of anesthesia. To these results
Lazear, as a member of the commission, contributed largely.
The final proof of their discovery that the disease is trans-
ferred by the bite of a certain mosquito, could only be ob-
tained by direct experiment upon a human being. To this
experiment Lazear, with another of the committee, courage-
ously and heroically subjected himself, and in tlic perform-
ance of this noble duty he lost his life.

The many friends and admirers of the talented and accom-

216

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 134.

plished student, of the brave, trae, self-sacrificing man,
desire to establish a lasting memorial to him and to his work.
To this end a meeting was held on the evening of Wednes-
day, May 28d, which was presided over by Professor William
Osier. At this meeting it was concluded that the nature of
the memorial could better be decided upon when some idea
could be obtained as to the amount of money available. It
was, therefore, decided that a committee consisting of Dr.
Stewart Paton and Dr. William S. Thayer be appointed to
arrange for the distribution of a circular among the friends
and admirers of Lazear, setting forth the object of the meet-
ing. It is earnestly hoped that not only those who have

known and admired Lazear and his work, Imt also others,
who appreciate courage and manliness and self-sacrifice, may
contribute to the fund for the Jesse William Lazear Me-
morial.

Subscriptions may be sent to Dr. Stewart Paton, Treas-
urer, 213 West Monument Street, Baltimore, Md. It is to be
hoped that the response to this circular may be made early,
as it is hoped to be able to decide upon the nature of the
memorial by the middle of June.

William Osler, Chairman.
Stewart Paton, "1 „

William S. Thayer, >

ommitlee.

PROCEEDINGS OF SOCIETIES.

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
Decemler 17, 1900.

The meeting was called to order by tbe ]ii-csi(1ent , Dr. W. H.
Welch.

Dr. Futcher exhibited a case of Kheumatisni with Fibroid
Nodules.

Discussion.

De. Welch. — So far as I am aware, the pathology of these
subcutaneous nodules in rheumatism is obscure. Some are
so transitory in nature that they are probably attributable to
a circumscribed inflammatory oedema; others may persist for
weeks and months and are characterized by new formation of
connective tissue. It has been suggested that they may be
tropho-ncuroses. Dr. Cheadle has called attention to the
analogies between these nodules and certain fibroid nodules
and thiekenings of the endocardium in rheumatism. In the
only sjiecimen which I have examined the nodule contained
dense, fibroid tissue, partly hyaline in character.

Tlie Intrinsic Blood-Yessels of the Kidney and tlicir Significance
in Neplirotoniy. Mk. Bkodel.
(See page 10, Bulletin for January, 1901.)

Discussion.

De. Hunnee. — Dr. Kelly not being present 1 take the
liberty of reporting improved results in his operations for
stone since following a definite plan for opening the kidney
as outlined by Mr. Brodel.

Formerly he split the kidney, as I suppose most surgeons
do to-day, along the line of greatest convexity, thus carrying
the incision through the main column of cortical substance,
or just that portion as shown by Mr. Brodel's drawings, which
sliould be avoided.

I have begun experimental work upon dog's kidneys to
determine the ultimate effect upon the kidney substance of
flifferent incisions and different suture materials. In the
few operations I have already performed I have been able to
demonstrate the value of Mr. Brodel's work as regards hsemor-
rhage. Cutting through the bases of the pyramids, as deter-

mined by the arrangement of the stellate veins of the surface,
or in the periphery, by the lobulations, results in decidedly
less hajmorrhage than follows splitting the kidney without
considering these anatomical points.

De. Welch. — Did your investigations extend to the ques-
tion of anastomosis between the renal vessels and the lumbar
and ureteral vessels? It is well known that if one of the
branches of the renal arteries be occluded, the area supjilied
by it dies, with the exception of a small zone of tissue at the
base of the infarct just beneath the capsule. This is due to
anastomosis with branches from the lumbar arteries.

Me. Brodel. — I found these vessels very frecpieutly but
noted nothing different concerning them from what is usually
stated in the books.

De. Welch. — Did you take up at all the question of origin
of the vasa recta?

Mr. Brodel. — I found that these come from the vessels at
the base of the pyramids and not from the glomeruli.

De. Welch. — I am sure that from many points of view,
Mr. Brodel's communication is an important one. I am
especially impressed by the number of new gross anatomical
points brought out. It shows that gross human anatomy is
not thoroughly worked out even yet.

A Case of Arterial Disease, po.ssibly Periarteritis Nodosa.

Du. Sabin.

(See page 195.)

January 7, 1901.

The meeting was called to order by the president. Dr. W. II.
Welch.

Typlioid Infection witliont Lesion of tlie Intestine. A case of
Ha'morrliag'ic Typlioid Fever witli Atypical Intestinal
Lesions. Du. Oi'ik and Mh. Bassett.

(See page 108.)

Report npon IJ. niortiferns. Dit. Harris.

The history of the ease from wliicli this organism was
obtnined is briefly, as rnllows: Tlie pntiout, n wliite man aged

July, 1901.)

JOHNS HOPKINS HOSPITAL BULLETIN.

217

44, was admitted on the 6th of October to Dr. Ilalsted's
service. His liistory, both family and personal, was jiarticu-
larly good. Four days previous to his admission he had
complained of severe headache which was followed by nausea
and vomiting, the latter continuing until his entrance to the
hospital. The patient fancied that the vomited material had
a fecal odor, and after such spells of nausea he was unable to
eat for nearly 24 hours. Two days before coming in, abdomi-
nal pain began and remained constant over the whole right
side. On being a.sked to put his hand to the spot of greatest
tenderness, he placed it to the right of the um1)ilicus and in
the upper right quadrant of the abdomen. On the day of
entry he was seized with a chill and this was followed liy
profuse sweating. His temperature on admission was 10:3°
with a leucocytosis of 36,000.

On physical examination, liver dullness extended from the
Gth rib 8 em. downwards towards the central line of the
abdomen. Upon palpation, the left side of the abdomen was
soft and not tender or rigid. Tlierc was slight tenderness in
the lower right quadrant, but no definite mass could be felt
beneath the area of muscle spasm.

His condition became gradually worse, his leucocytosis vary-
ing between 7000 and 20,000, and his temperature ranging as
high as 10.5°. On the 9th, Dr. Halsted saw the patient and
advised an exploratory operation under cocaine. The con-
dition found was this: the mass below the costal margin was
the liver and upon its surface were numerous abscesses with
thin walls. During the manipulation of the liver, one of
these abscesses ruptured and discharged its contents into the
jieritoueal cavity. The abdomen was cleaned and the liver
packed around with gauze to prevent any further pollution.
The patient did not seem to do well, however, after the oper-
ation and the symptoms were scarcely improved in any way,
though the patient stated that he felt much more comfort-
al)le. The dressings were soaked with a discharge of foul
odor, the leucocytes continued to rise and later in the evening
he had a chill followed by a temperature of 105°. He died
on the 1.3t]i.

Coverslips made at the time of operation showed many
cocci and a few bacilli with pus cells and much debris. The
autopsy was performed 5 hours after death liy Dr. Opic.

Cultures were made at the autopsy in the ordinary manner
on plain agar and left for 48 hours before being examined.
At the end of that time it was found that they had become
contaminated. I then endeavored to make cultures from the
abscesses in the liver. On microscopic examination of cover-
slips prepared from this pus I was led to believe that I had
to d(>al with an organism that would be rather difhcidt to
cultivate by ordinary means, so cultures were made on hydro-
cele fluid agar as well as on i)lain agar, and these were both
grown aiirobically and anaerobieally. Both sets of the aerolu'c
l)lates were entirely sterile at the end of 48 hours. On the
hydrocele plates grown in liydrogon, only one showed growtb,
and that was the first plate made undiluted from the abscess.
The plain agar plate similarly grown was sterile, although tln'
plate showed a great deal of debris from the abscess. The

appearance of the successful plate was peculiar; surrounding
three minute pieces of necrotic material were zones of very
fine colony formation about 8 mm. in diameter. When
viewed under the single lens these were shown to be made up
of very minute colonies which were transparent and of a
slightly yellowish color. Some were irregular, some oval and
some round. Coverslips from these showed an organism that
corresponded almost exactly with that obtained from th;.' liver
abscess material. Upon the whole, it was a very miiiulc
bacillary fofm occurring singly or in pairs; at times the pairs
were so small that one could not positively say they were not
diploeocci; again were seen forms growing in chains resem-
bling streptococci or streptobacilli. Perhaps the morphology
of the bacilli from the cultures on the hydrocele fluid agar
were slightly larger than those obtained directly. This was
not constant, however, for cultures made later showed that
the organism could grow quite as small as those found in the
abscess. To make sure that I was not dealing with a con-
tamination, cultures were made from individual colonies and
it was found that no growth occurred on any media gi'own
aerobically or anaerobieally and occurred on the hydrocele
agar, only, in the presence of hydrogen. From these latter,
plates were again grown to rule out any chance of contami-
nation. It was soon found that the organism would not
grow upon any medium that did not contain as a basis, blood,
blood-serum, or hydrocele fluid. I was unable to obtain any
ascitic fluid with which to work, but it is likely that it would
have grown upon that also.

The organism grown in hydrocele fluid agar was able to
form gas, but that undoubtedly arose from its action upon
muscle sugar. Even when dextrose-free medium was used,
there was still some gas-formation. A shake culture in
hydrocele-fluid-glucose-agar gave an abundant amount of gas
of bad odor, almost fecal. In hydrocele fluid milk there was
a slight acidification with doubtful coagulation on the fourth
day and a clearing up (" peptonization '') on the Gth day, until
the tube became semi-transparent with a thick sediment at
the bottom, made up largely of a growth of the organism.
On examining very closely a hydrocele fluid bouillon cul-
ture, small Imbbles of gas were noticed rising to the surface
during the first 48 hours. In Dunham's medi^un, to which
hydrocele fluid had been added, the same phenomenon was
observed. The organism would not grow on Lofiler's ox-
blood serum.

Whilst engaged in this cultural work, experimental work
was not neglected. A rabbit was inoculated with pus from
the same abscess from which I obtained the organism. The
animal received .3 cc. intravenously in the afternoon, and
was found dead the next morning at 8 a. m. The autopsy
showed nothing and cultures were negative. Sections of the
tissue examined later, however, showed lesions. Another
rabbit was inoculated with .4 cc. of bouillon culture, remained
well for two and one-half days and then gradually weakened,
became thin, and died on the Gth day. All of the animals
inoculafed afterwards went tbroiigh (lie same course of grad-
n:il weakening and emaciation, but ate very well up to the

218

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 134.

day of death, which on the average was the 6th day after
inoculation. Post-mortem, the lesions of these animals were,
generally speaking, emaciation, loss of subcutaneous fat and
a tremendous degree of peritonitis; most of them showed a
great exudation into the abdominal cavity of bloody fluid,
containing much coagulated lymph. The surfaces of the in-
testines and abdominal organs were coated with a fibrino-
purulent material. The spleen, as a ride, was usually more
or less completely encased in such a sheath, and in one in-
stance it was found with difficulty. The livers were larger
than normal and were found to be studded with yellowish-
white round nodules. I was not able to find the fluid con-
tents in these experimental abscesses, as was seen in tlie liver
of the human subject. The consistency of the material in
these abscesses was putty-like. In some of the rabbits, ab-
scesses were found in the heart's muscle and in the cerebral
hemispheres. In one guinea-pig were found lesions in the
lungs quite comparable to those in the human subject, and
in one of the rabbits there was a complete infarction of the
spleen, due to plugging of the splenic vein.

On looking over the literature one is impressed by the lack
of systematic anaerobic investigation, and, with few excep-
tions, what has been done is without much value. The best
of the kind is that carried out by two investigators in Paris,
Veillot and Zuber, which will be found, published in 1898, in
the Archiv do Medicine Experimcntalcs. They isolated from
a case of gangrene two very small organisms but quite unlike
the one I have described. In addition, from 23 cases of ap-
pendicitis, they found anaerobic bacilli associated with bacil-
lus coli and streptococcus; in all, I think, they isolated some
7 varieties, and in 2 cases found anaerobes in pure cultures.
Likewise, a pupil of theirs. Guillemot, has since written, for
his thesis, a paper, which confirms their work on these organ-
isms, and, in addition, he describes three or four more varie-
ties. These in no wise heai" any relation to the one described
this evening, for they were cultivated upon a medium we all
use regularly in our laboratories, glucose-agar, and they grew
on all other media, if given anaerobic surroundings; whereas
the organism presented to you this evening will not grow so,
but requires some such medium as hydrocele fluid, blood or
blood-serum, to be added to the ordinary media before growth
occurs.

The name proposed for this organism, bacillus mortiferns,
is chosen in accordance with the ordinary classification, but,
if that of Migula is used, thei bacterium mortifer woidd bi'
more proper.

Discussion.

Dr. "Welch. — It is certainly most fortunate that Dr. Harris
had from the examination of cover-slips smeared with tlic
fresh material an instinctive feeling, such as will be \mder-
stood by experienced bacteriologists, that the delicate, un-
usual bacillus would be difficult to cultivate, and that it
occurred to him to inoculate, among other media, tubes con-
taining hydrocele fluid. Dr. Harris has brought conclusive
evidence that the organism cultivated is identical with tlie

one found microscopically in the original liver, and that it is
responsible for the remarkable lesions of this organ. No
especial emphasis need be laid upon the consistence of the
pus in the experimental abscesses produced by this bacillus in
rabbits, as it is well known that the pus of rabbits usually has
a putty-like or cheesy consistence.

Two Cases of Amoebic Dysentery in Children. Du. Amberg.

(To appear later.)

January 21, 1901.

In the absence of the president, the meeting was called to
order by Dr. Kelly.

Exiiihition of Surg-ical Cases. Dr. Mitchell.

Dr. Mitchell exhibited a case where the gasserian ganglion
had been excised after the method of Dr. Gushing for a
patient who had suffered from facial neuralgia for thirteen
years, with the effect to produce complete relief from pain.

The second case was one of operation for typhoid perfora-
tion of the intestine, with recovery.

Discussion.

De. Futcher. — This case interested us very much clini-
cally, and three or four points in connection with it were of
special interest in arriving at the diagnosis of perforation.
The child had had a tub at 6 P. M. and had been placed
back in bed. At 7.15 she suddenly cried out with intense
abdominal pain. A count of the leucocytes was made about
this time, on the possibility of some acute complication having
taken place, and they were found to be 11,500. The child
complained slightly of the pain during the evening but
about 11 o'clock when Dr. McCrae was making the late visit
in the wards, the patient again cried out with intense pain.
He called me and we went over the ease together. At
that time the abdomen was moderately distended, there was
distinct rigidity of the muscles and slight muscle spasm.
The liver dullness extended only to a point 3 cm. above the
costal margin; before this it had extended quite to the
margin of the ribs. The child had a peculiar facial expres-
sion, the mouth was rather puckered up and while examining
her she suil'ercd spasms of severe abdominal pain which made
her cry out. A count of the leucocytes at that time showed
that they had fallen to 7000. By 13 o'clock her condition
had changed materially. The pulse was weaker, more rapid
and of a running character; the abdominal distention was
more marked; there was then definite muscle spasm and ten-
derness in the right iliac fossa on the slightest palpation.
There was also appreciable movable dullness in the flanks.
There had been jjractically no change in the temperature.
The sudden onset of the pain and its paroxysmal character,
the increased frequency in the pidse, the abdominal disten-
tion, muscle rigidity and spasm, the diminution in the area of
hepatic flatness and the movable alidominal dnllness made
it reasonably certain tliat a jicrforation had occurred. Dr.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

219

Mitchell saw the patient shortly after 13 midnight and agreed
that an operation was advisable. Tlie operation was per-
formed about 8 lioiirs after the time at wliich perforation liad
occurred.

Healed Amoebic Abscess of tlie Liver, and Amoebic Abscess of
the Liiug'. Exbibitious of Specimens. Dr. Opie.

The patient was admitted to tlie hospital March 1, 1900,
complaining of pain in the right side and shoulder. lie had
had dysentery for 13 months but it had disappeared three
niontlis before his admission. For about six months ho had
had pain in the right side and in the right shoulder. When
admitted he was emaciated and pale and his skin had a
yellowish hue. There was bulging of the lower portion of
the right chest below the level of the 5th rib and distention
of the abdomen on the right side below the costal margin.
The dullness began at the 5th rib in the mammary line, at
the 6th rib in the mid-axillary line and at the 8th rib in the
line of the angle of the scapula; it extended about 8.5 cm.
below the costal margin in the right mammary line. Several
exploratory punctures were made but the bloody fluid ob-
tained contained no amrobfe. There was no diarrhoea and
amcebiE were not found in the stools.

An operation was performed by Dr. Gushing seven days
after admission. The 10th rib was resected in the mid-
axillary line and a large abscess cavity entered. It contained
about a litre of chocolate-colored fluid in which were necrotic
particles. The discharge after the operation was profuse,
and in it on the second day actively motile amoebae were
found. The cavity was irrigated with quinine solution varj^-
ing in strength from 1 to 1000 to 1 to 3000. The discharge
gradually diminished in amount and at the end of six weeks
had completely disappeared. Amoebse were frequently found
during this period.

On the 5th day after the operation the patient was attacked
with cough, which gradually increased in severity and was
accompanied by the expectoration of mucopundent material.
At first nothing specific was found in this material but later
actively motile amoebae were discovered. As the cough be-
came worse signs of consolidation appeared over the lower
right chest. Eight weeks after the first operation the ril>
was resected in the anterior axillary line but no abscess cavity
was found. A second incision made through the 5th rib at
the juncture of the costo-chondral line entered an abscess
cavity from which was evacuated a large amount of purulent
fluid. The material discharged from this cavity contained
numerous amoebffi. On the 4th day after operation occurred
a profuse hismorrhage, with which about a pint and a half of
blood was lost. A second haemorrhage took place eight days
later and death followed.

The ease was one of dysentery followed by an amoebic
abscess of the liver. The dysentery was presumably of the
same character though amoebae were not found in the stools.
Following operation the liver abscess healed but death fol-
lowed the formation of a secondary abscess in the lung.

At autopsy was found in the right lung the large abscess

cavity which is well seen in the preserved specimen. The
pleura was adherent to the chest wall and the abscess cavity
occupied almost the entire anterior half of the middle and
lower lobes. The walls are irregular and covered with a
soft necrotic material. In the liver, the abscess cavity which
two months before death contained a litre of purulent fluid
is represented by a small mass of dense fibrous tissue 3 cm.
across. In 1 he ascending colon and in the coecum were numer-
ous pigmented scars, while in the sigmoid flexure were one
or two very superficial ulcers. In the contents of the lung
cavity were numerous motile amccbffi. None could be foimd
in material scraped from the intestinal ulcers, though it can
be hardly doubted that amoebae were present during the active
stage of the dysentery.

The etiological relationship of amoeba? to so-called amrebic
dysentery is not entirely undisputed. The presence of
amoebai in the walls of abscesses in organs distant from the
infected intestines furnishes the best evidence of their patho-
genicity. The amoebae are constantly associated with one
form of dysentery characterized by the occurrence in the
large intestine of a lesion whose distinctive feature is necrosis
and softening of the sidjmucous tissue with the production
of irregular ulcers with undermined edges. That they are
the causal factors in the production of the disease has been
questioned since on the one hand a variety of bacteria are
always present and on the other hand similar amceba? have
been found by Cunningham, Grassi, Schuberg and others in
the stools of healthy individuals and of those suffering with
other diarrhoeal diseases.

Belief in the pathogenicity of the Amoeba coli is justified
by certain facts: (1) Amoebae are constantly associated with a
form of dysentery which is characterized by peculiar anatomi-
cal.lesions; they occur within the lesions and in the discharges
from them. (2) They are found in abscesses of the liver and
of the lung accompanying this form of dysentery but are not
found in other abscesses of these organs. (3) Though the
anatomical picture of chronic tropical dysentery has not been
reproduced in animals, an inflammatory condition of the large
intestine accompanied by multiplication of the organism in
the lumen of the intestine and in the affected tissue has been
produced (Kruso and Pasquale) by injecting into the rectum
of cats purulent material from liver abscess containing only
amoebae. The injection of non-dysenteric faecal material con-
taining amcebffi has not caused a similar condition.

Exliibition of a Case of Osteoma of External Auditory Caual.

Dr. Randolph.

It is seldom we have the opportunity of seeing new growths
in the external auditory canal. The most common one is an
osteoma, which occurs either as a localized exostosis or as
a more diffuse hyperostosis, the etiology of which is rather
obscure. Buck, of New York, thinks that they are often
due to the irritation produced by a chronic discharge. I
doubt very much whether this is the true interpretation of it.
We know how frequently otorrhoca is seen and how seldom
we meet with an exostosis.

220

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 12 [.

The treatment does not call for aggressive measures except
ill a very limited number of cases. If the patient is quite
deaf in one ear and an osteoma is interfering with the better
car, then an operation should be undertaken. Or if there
is a discharge from that ear the tumor should be removed
lest its gi'owth .should close the orifice and cause serious
symptoms. Otherwise the tumor is allowed to stay. When
it completely fills the canal its development seems to come
to a standstill and it gives no further trouble than to inter-
fere with hearing. The great trouble about operative meas-
ures in these eases is that it is very diflTieult to remove the
tumor without running some risk of producing inflammation
which may extend to the drum membrane and produce a
more serious condition. Last year I made mention, in my
report in " Progressive Medicine," of the only other case T
have seen and upon which I operated successfully. The man
was quite deaf in one ear and the osteoma was attached to
the superior wall, and apparently filled the whole external
auditory canal nearly to the drum membrane. I perforated
the growth by applying to it nitrate of silver fused on the
end of a probe and applying it at long intervals until I had
gotten clean through the growth. It produced such a dis-
turbance in the nutrition of the growth that it was easily
broken down and in 3 months' time the canal was entirely
clear. This seems a long and rather tedious treatment to
adopt but it was attended with no irritative symptoms and
was followed with complete success.

This boy's osteoma fills up the canal entirely but I have not
suggested any operation here, because it docs not seem to be
called for.

Sii.speusioii of the Kidney. An Extensive Vcsiio-Vayinal Fistiilii.
Dr. Kelly.

(To appear later.)

February J,, 1901.

Exhibition of .Medical Cases. Chronic Jaundice with Xanthoma
Multiplex. Dk. Uslek.

The patient, aged 39, had typhoid fever with cholelithiasis
in 1897 and has had three attacks of biliary colic (the first in
December, 1899), characterized by pain, vomiting, chills,
fever, sweats and Jaundice, and following each attack the
jaundice has deepened. The form of jaundice is that asso-
ciated with stone in the common duct, that is to say, inter-
mittent in character and deepening after the attacks of colic,
etc. The unusual complication is the presence of what is
known as Xanthoma multiplex.

All of you have noticed, especially in brunettes, a distinct
little tumor on the eyelids, sometimes on both but usually on
the lower lid, the common Xanthelasma palpebrarum. In a
few rare instances these remarkable tumors are widely dis-
tributed over the body, usually in connection with chronic
jaundice. Oddly enough Dr. Sabin a day or two ago met
another patient with the same condition in chronic jaundice.

In a few rare instances multiple Xanthelomata have oc-
curred in young persons without jaundice. Not only do the

tumors occur in the skin but in a few cases in the mucous
membranes, on the serous surfaces and in the bile passages,
the gall-duct and gall-bladder. In this patient the distribu-
tion is on the hands, elbows, axilla;, neck and on the toes;
they are chiefly in the folds and at points of irritation.

The yellow color is due to the presence of supposed cluu-
aetcristic cells sometimes spoken of Xantheloma cells, which
undergo a fatty degeneration and the color is due to the fat.
Occasionally these tumors undergo complete involution and
thus disappear. This patient will have an operation |ier-
fonned for removal of the gall-stone and it is to be hoped the
tumors will disappear, but in any case they are never serious,
do not grow very large and are a source of annoyance only
through the slight disfigurement produced. She has one
patch on the mucous membrane of the upper lip but there are
only a few small ones about the eyelids.

Discussion.

De. Welch. — I hope that a careful histological study will
be made of specimens of the xanthomatous lesions in this
case, as the subject is one offering many unsolved problems.
My attention was directed a few years ago to Xanthoma
through the opportunity of examining sections sent to me by
Dr. Pollitzer of New York, whose specimens were iitilized by
Unna in his description of generalized Xanthoma. The spec-
imens which I examined were of ordinary Xanthoma palpe-
brarum. There ajipcar to be at least three, and probably
more, clinical types of disease which have been called Xanthe-
lasma or Xanthoma, namely, Xanthoma vulgare of tlie eye-
lids, an extremely common and unimportant affection, juve-
nile Xanthoma multiplex, and genalized Xanthoma of adults,
most frequently secondary to jaundice and diabetes mellitus,
but occurring also without any apparent cause. Unna makes
a sharp histological difference between the common form of
pal]iebral Xanthoma and generalized Xanthoma. According
to him, in the former the fat, which gives tlie yellow color
to the lesion, is of a peculiar character and lies in extracellular
masses within the lymphatic spaces and vessels, there being
no true Xanthoma cells. I am not aware that Unna's views,
which are not in accordance with those usually accepted, have
been confirmed. Waldeyer in his first publication and most
other investigators following him find the fat in small gran-
ules or droplets within large cells believed to be derived from
connective-tissue cells or endothelial cells, these fatty cells
being the so-called Xanthoma cells. Later Waldeyer sug-
gested that these cells may come from his plasma cells or
Toldt's embryonic fat-forming cells, and this view has had a
number of advocates. Dr. Pollitzer finds evidence in his
sections of palpebral Xanthoma that the characteristic cells
containing fat are derived from striped muscle, partly dis-
placed through congenital abnormality into the corium.
Virchow objects to the designation " Xanthelasma " or " Xan-
thoma," as not based upon histological characters, and has
proposed, as a substitute, fibroma lipomatodes, but this sug-
gestion seems to have met with little success. There is a

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

221

rare form of lipoma which bears considerable anatomical
resemblance to certain of the larger neoplasms which have
been described as Xanthomata. I examined such a specimen
some years ago. It was a lobulated and encapsulated subcu-
taneous tumor, the size of a hen's egg, removed from the groin
of a young man, and believed at the operation to be an ordi-
nary lipoma. On section it presented a uniform, yellow sur-
face, and microscopically it was composed entirely of vascular
stroma and large cells filled with minute granules or droplets
of fat. After removal of the fat single, or occasionally mul-
tiple, round or oval nuclei with nucleoli were found usually
about the middle of cells filled with a iinely porous or reticu-
lated protoplasm. There was a stroma around individual
cells or groups of cells. I interpreted the tumor as composed
of embryonic adipose tissue. There were no adult adipose-
tissue cells with single, large oil-drops. I mention this tumor
on account of its histological resemblance to certain xantho-
matous tumors, but otherwise it has no relation to Xanthoma,
as it was the only new growth and was in the subcutaneous
tissue. It is highly probable that a variety of distinct affec-
tions have been described under the name of Xanthoma.

A Cise of Arsenical Neuritis. Dk. Sabin.

The patient is a young woman who was bronglit to the
hospital two months ago, November 23, 1900, after having
taken about a dram of Bough on Hats. She came in a few
hours later saying she had felt well for two hours after taking
the poison but had then begun to vomit. Her stomach was
washed out repeatedly and large doses of the antidote given,
together with epscm salts and castor oil. The only trouble-
some symptoms she exliibited while in the hospital were
nausea and vomiting. She was dismissed in five days feeling
well, but noted that on walking up the steps of her home her
feet were numb and the steps felt soft. She was soon able
to be up and about but the numbness of the feet never left
her. On January 1 she had an attack of painful micturi-
tion that was followed by fever lasting six days. The numb-
ness of the feet gradually increased and she became unable
to walk.

When she came to the hospital again she had double foot-
drop and wrist-drop, the muscles involved, however, were not
entirely paralyzed. Her hands were so weak that she could
not feed herself. Electrical reaction was given only with
strong ciuTcnts. There was delayed sensation over the legs
and arms, and slight impairment in the fingers and toes but
no complete anesthesia. There was hyperresthesia of the
soles of the feet so that the slightest touch caused pain and
muscle spasm. When she came in tlicre was some keratosis
over the soles of the feet. The palms of the hands were not
thickened but since admission some keratosis has developed.
The skin is everywhere dry and scaly. On both hands there
is a white line running transversely across each nail. The
skin reflexes are increased, the deep reflexes absent.

Discussion.

Dr. Osler. — It is interesting that neuritis seen in general
practice occurs in persons who have taken a considerable
quantity of arsenic at one time and not in those who take a
large cpiantity over a prolonged period. Arsenic is one of
the medicines most commonly used, and yet we rarely see a
neuritis following it. We have had but one case before in
the hospital and that patient took one ounce and two drachms
of Fowler's solution. There has been in the city a case (seen
by Dr. Carey Gamble in consultation) of fatal neuritis follow-
ing the use of arsenic for chorea. Arsenic is a drug that
may be taken in considerable doses for long periods without
any damage whatever, and the cases of neuritis that do occur
are probably in patients who have an idiosyncrasy for it.
Hutchinson reports a case of a man who had taken arsenic
nearly all of his life and without showing even pigmentation.

A Case of Peuiphig:iis Vegetaus. Du. IFambukgek.

(To appear, with discussion, later.)

Tlie Frequency of Typlioid Bacilli iu the Ulootl. Dr. Cole.
(See page 203.)

SUMMARIES OR TITLES OF PAPERS BY MEMP.ERS
STAFF APPEARING ELSEWIIFRE

Charles Eussell Bardeen, M. D. The Function of the
Brain in Planaria Maculata. — American Journal of
Physinloijy, Vol. V, No. 3.

and Arthur Wells Elting, M. D. A Statistical

Study of Variations in the Formation and Position of
the Lumbo-sacral Plexus in Man. — Anatomischer Anzei-
ijer, Bd. 19, Nos. 5-6.

Lewellys F. Barker, M. D. On the Importance of Patho-
logical and Bacteriological Laboratories in connection

OF THE HOSPITAL AND MEDICAL SCHOOL
THAN IN THE BULLETIN.

with Hospitals for the Insane. — Indiana Medical Jour-
nal, January, 1901; The American Journal of Insanity,
January, 1901.

The So-called Cardiac Neuroses: Classification;

Etiology; Pathology. — Chicago Medical Recorder, May,
1901.

Bates Block, M. D. Enchondroma-like Formations in
the Femur, following Osteomyelitis. — Journal of Pathol-
ogy and Bacteriology, February, 1901.

222

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 134.

Joseph C. Bloodgood, M. D. Blood Examinations as an
Aid to Surgical Diagnosis. — American Medicine, May 18,
1901.

Thomas II. Brown, M. D. A Eeview of Some of the Recent
Work on the Physiology and Pathology of the Blood. —
Maryland Medical Journal, December, 1900; February,
March, April, May, 1901.

The Prospect in the Treatment of Lobar Pneu-

monia.— Maryland Medical Journal, January, 1901.

Urinary Hyperacidity: A Consideration of Cases

with Symptoms Suggestive of Cystitis, but with no In-
fection, Due to this Cause. — Plnladelphia Medical Jour-
nal, March 2, 1901.

Notes on the Blood and Vesicle Cells in Dr. Smith's

Case of Epidermolysis Bullosa. — Maryland Medical
Journal, April, 1901.

On the Relation Between the Variety of Micro-Or-

ganisms and the Comjjosition of Stone in Calculous
Pyelonephritis. — Journal of the American Medical xisso-
ciation. May 18, 1901.

Thomas S. Cullen, M. D. The Cause of Cancer. — Ameri-
can Medicine, May 18, 1901.

Haevey Cushing, M. D. Concerning Prompt Surgical In-
tervention for Intestinal Perforation in Typhoid Fever,
with the Relation of a Case. — An7ials of Surgery, May,
1901.

and Bruce W. Goldsborough, M. D. A Rare

Form of Extrauterine Pregnancy. — American Medicine,
April f), 1901.

SuV la Laparotomie Exploratrice Precoce dans la

Perforation Intestinale au Cours de la Fievre Typhoide.
— Archives Generales de Medecine, January, 1901.

Simon Flexner, M. D. Experimental Pancreatitis. — Uni-
versity Medical Magazine, January, 1901.

Etiology of Dysentery. — The Journal of the American

Medical Association, January 5, 1901.

The Etiology of Tropical Dysentery. — Centralblatt

fiir Bakteriologie, Erste Abt., Bd. 28, No. 19.

William W. Ford, M. D. Variation of the Properties of the
Colon Bacillus, Isolated from Man. — Journal of the Bos-
ton Society of Medical Sciences, January 15, 1901.

Obstructive Biliary Cirrhosis. — American Journal of

the Medical Sciences, January, 1901.

On the Bacteriology of Normal Organs. — The Jour-
nal of Hygiene, Vol. I, No. 2.

Thomas B. Futcher, M. D. Syphilitic Fever, with a Report
of Three Cases. (From the Service of Professor Wil-
liam Osier.) — New YorTc Medical Journal, June 22, 1901.

Norman B. Gwyn, M. D. The Disinfection of Infected
Typhoid Urines. — Proceedings of the Phila. County i[cdi-
cal Society, Vol. XXI, No. 7; Philadelphia Medical Jour-
nal, January 12, 1901.

Norman Harris, M. D. A Preliminary Report upon a
Hitherto Undcsci'ibcd Pathogenic Anaerobic Bacillus. —
Journal of the Boston Society of Medical Sciences, Febru-
ary 19, 1901.

Ross Granville Harrison, M. D. Ueber die Histogenese
des peripheren Nervensystems bei Salmo salar. —
Archil! fiir MU'roslvpische Anatomic, Bd. 57, Heft 2.

Albion Walter Hewlett, M. D. The Superficial Glands
of the Oesophagus. — The Journal of Experimental Medi-
cine, Vol. V, No. 4.

Henht Barton Jacobs, M. D. A Short Account of the Re-
cent International Medical Congress in Paris. — The
Boston Medical and Surgical Journal, January 10, 1901.

Four Cases of Sporadic Cretinism. — Maryland Medi-

cal Journal, March, 1901.

Howard A. Kelly, M. D. Jules Lemaire. The First to
Recognize the True Nature of Wound Infection and
Inflammation, and the First to Use Carbolic Acid in
Medicine and Surgery. — Journal of the American Medi-
cal Association, Aj^ril 20, 1901.

How to Deal With the Vermiform Appendix: Some

Forms of Complicated Appendicitis. — American Medi-
cine, April 20, 1901.

Thomas McCrae, M. D. Abdominal Pain in Typhoid Fever.
— New York Medical Journal, May 4, 1901.

G. Brown Miller, M. D. The Streptococcus Pyogenes in
Gynecologic Diseases. — Journal of the American Medical
Association, May 18, 1901.

M. Adelaide Nutting. The Preliminary Education of
Nurses. — 'The American Journal of Nursing, March,
1901.

Eugene L. Oeie, M. D. The Relation of Cholelithiasis to
Disease of the Pancreas and to Fat Necrosis. — American
Journal of the Medical Sciences, January, 1901.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

223

On the Eelation of Chronic Interstitial Pancreatitis

to the Ishmds of Langerhans and to Diabetes Mellitus.
— The Journal of Experimental Medicine, Vol. V, No. 4.

The Relation of Diabetes Mellitus to Lesions of the

Pancreas. Hyaline Degeneration of the Islands of
Langerhans. — The Journal of Experimental Medicine,
Vol. V, No. 5.

WiLLiAJi OsLER, M. D. On Perforation and Perforative
Peritonitis in Typhoid Fever. — Proceedings of the Phila-
delphia County Medical Society, January, 1901, and
Philadelphia Medical Journal, January 19, 1901.

A Plea for the More Careful Study of the Symp-
toms of Perforation in Typhoid Fever with a View to
Early Operation. — Tlie Lancet, February 9, 1901.

The ]\[edieal Aspects of Carcinoma of the Breast,

with a Note on the Spontaneous Disappearance of
Secondary Growths. — American Medicine, April 6 and
13, 1901.

Hemorrhage in Chronic Jaundice. — American Medi-

cine, April 37, 1901.

— ■ The Study of Internal Medicine. — Medical News,
April 27, 1901.

The Natural Metliod of Teaching the Subject of

Medicine. — Tlie Journal of the American Medical Asso-
ciation, June 15, 1901.

Lindsay Pkters, M. D. Resection of the Pendulous, Fat
Abdominal Wall in Cases of Extreme Obesity. — Annals
of Sunjcry, March, 1901.

Henry 0. Reik, M. D. The Value of Formaldehyde in the
Treatment of Suppurative Otitis Media. — Maryland
Medical Journal, January, 1901.

Hunter Robb, M. D. The Treatment oE Nausea and Vom-
iting Following Anaesthesia after Abdominal Opera-
ations. — Cleveland ]\[edical Gazette, February, 1901.

B. R. ScHENCK, 1\I. D. Four Cases of Calculi Impacted in
the Ureter. Nephro-Ureterectomy, Abdominal Uretero-
Lithotomy, Vaginal Uretero-Lithotomy. — Journal of the
American Medical Association, May 11, 1901.

Walter R. Steiner, M. D. Dermatomyosites, with Report
of a Case which also Presented a Rare Muscle Anomaly,
but Once Descrilied in Man. (Abstract.) — Journal of
the Boston Society of Medical Sciences, February 19, 1901.

Samuel TnEOBALD, M. D. The Evolution of the Ophthal-
moscope and what it has done for Medicine. — New York
Medical Journal, June 22, 1901.

George Walker, M. D. Curetting the Urethra in the
Treatment of Chronic Posterior Urethritis. — Maryland
Medical Journal,'M.a,rch, 1901.

Tuberculosis of the Vesiculae Semiuales, Testes and

Prostate; Complete Excision of Right Side; Incision
and Curetting on Left Side: Cured. — Maryland Medical
Journal, February, 1901.

William H. Welch, M. D. Distribution of Bacillus Aero-
geues Capsulatus. (Bacillus Welchi, Migula.) — Journal
of the Boston Society of Medical Sciences, February 19,
1901.

Hugh H. Young, M. D. An Operating Table for Office
Work. — Maryland Medical Journal, March, 1901.

— . Ueber ein neues Verfahren zur Esstirpation der

Sameublasen und der Vasa deferentia, nebst Bcricht
liber zwei Fiillc. — Archiv fiir Minische Chirurgie, Bd. G3,
Heft 3.

NOTES ON NEW BOOKS.

Golden Rules of Surgical Practice. By E. Hurry Fknwick;,
V. 11. C. S. Uolden Itiiles Series, No. I. Fifth edition. Re-
vised and enlarged. {Bristol: John Wri<ilit £ Co.)

Golden Rules of Obstetric Practice. By W. E. EoTnEKGiLi,, M. A..
B. Sc, M. D. Golden Rules Series, No. III. {Bristul: John
Wihjlit iC- Co.)

Golden Rules of Physiology. By I. Walker Hale, M. B., Ch. B.
(Vict.), and J. AcwoKTU Menzies, M. D., C. M. (Ed.). Golden
Rules Series, No. VI. {Bristol: John M'rinht d- Co.)

Golden Rules of Ophthalmic Practice. By Gustavus Haist-
RIDGE, E. R. C. S. Golden Rules Series, No. VII. {Brislol:
John Wriyht tC- Co.)

These little books have been i^ublished to aid students in pre-
paring for e.Naniinations, and, as one would naturally suppose,
they combine a maximum of information with a minimum of
space. Their size in fact suggests that tliey are intended to be
pocket-guides and private lig-hts until the shoals and reefs of an
examination are safely' passed. If guides are required in ci-am-
ming for an examination, these seem to be exceptionally well
written and printed, and can be commended.

Essentials of Histology. By Loins Leeoy, M. D. 72 illustrations.
{I'hiUnkliihiii: II'. B. Saundtrs <£ Co., 1900.) Price, .fl.

This small volume is a quiz compend with very diagrammatic
illustrations. It may afford solace to those contending against
the rigor of State Board examinations; but to the sincere stu-
dent of anatomy it is of little interest.

A Text-Book upon the Pathogenic Bacteria, for Students of Medi-
cine and Physicians. By Joseph McEarland, M. I). Third
edition. {l'hiUi(MiJiia: W. B. Saunikrs tC- Co., 1000.)

The second edition of this work was reviewed in the Bulletin
of December, ISOS.

We ask the attention of our readers to the vast improvement
made in this, the third edition, compared with that of its pre-

224

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

decessors; inaccuracies have been corrected, chapters carefully
rewritten, and much new and valuable material introduced.

Especially to be commended are the cjiapters upon Infection
and Immunity, which are made to embrace the latest views of the
various well-known authorities in these speculative fields of
research; the articles upon Tuberculosis, Diphtheria, Typhoid
Fever and Plague; whilst the chapters dealing with general tech-
nique have undergone satisfactory revision.

Dr. McFarland is to be congratulated upon the excellent merit
of this volume. N. MacL. H.

An American Text-book of Phj'siology. Edited by Wiij.iam Jt.
HowEU,, Ph.D., M. D. Second edition, revised. \o\. II.
(PhiliuMphUi: W. B. Saiiml-ers d Co., 1001.)

The second edition of the American Text-book of Physiology,
edited by Professor Howell, has recently been completed by the
appearance of its second volume. The first volume of this edi-
tion was placed before the public some time ago and was re-
viewed in the February number of the Bulletin. Most of the
opinions there expressed relating to the value of the work in
general might be repeated here, but such a rei^etition is con-
sidered unnecessary.

The second volume treats of the general physiology of muscle
and nerve, the central nervous sjstem, the sfiecial senses, of
special muscular mechanisms, and of reproduction. The authors
who contributed to the first edition have rewritten their respec-
tive subjects for this volume.

Professor Lombard's article on the general physiology of
muscle and nerve contains very much valuable knowledge,
knowledge that is especially interesting to tlie advanced student
in physiology. This is probably explained in part by the fact
that a very large amount of detail is introduced. But it is just
this that detracts, to some extent, from its value to the beginner.
In the treatment of such subjects as the sjiread of electrostatic
charges, the effect of temperature upon the irritability of nerve
and muscle, contraction in normal muscle following frequent
excitation, etc., the detail is almost sufficient to overwhelm the
average student. At the same time the brevity that the charac-
ter of the article necessitates leads to an inevitable lack of
clearness. The brief and incomi)lete reference to v. Furth's
work on the proteids of muscle will convey to the student
but a vague idea of its meaning- in the chemical and
physiological processes of muscle. On the other hand it is
noticeable that the article has been carefully brought up to
date. Practically all of the recent important work receives
notice. The rather vague statement of the neuron theory in
the first edition gives i)lace to a clear and definite exposition in
the i^rcsent volume. The additions to our knowledge of the
physiological processes in miiscle made through physical chem-
istry are referred to. The work of Bottazzi, Boncttau, Budgett,
V. l'\irth, and many others has been incorporated in the text.
In this connection we must say that Lombard has added an
interpretation to the work of Budgett and Green which these
authors do not mention. Lombard is discussing the question,
do nerve fibres conduct the impulse in both directions from the
point of stimulation? It will be remembered that Budgett and
Green cut the pneumogastric nerve between the ganglion and
the cranium, and then sutured its peripheral cut end to the
peripheral cut end of the hypoglossal. Three months after
operation stimulation of the central end of the vagus caused the
muscles of the tongue to contract. "... There would seem to
be no escape from the conclusion that the sensory fibres of the
pneumogastric had conducted the impulse centripetally as far
as the ganglion and then centrifugally down to the muscles of
the tongue." This is true, but in so doing the nerve fibres were
conducting in the direction in which they normnlly conduct —

first to the nerve cell, then from the nerve cell. At no time
was the impulse carried in a direction opposite to its normal
one. The experiment does not demonstrate the power of nerve
fibres to conduct in both directions.

The article on the central nervous system by Professor Don-
aldson has been rearranged and largely rewritten so as to render
this subject more " suitable to the needs of students and prac-
titioners." In a brief introduction generalizations are expressed
with a degree of simplicity and clearness that is charming.
As a general rule these attractive qualities of style are main-
tained throughout the article. It is to be regretted that the
author has permitted to appear in the text his categorical
descriptions of the cranial nerves. It is true that the student is
referred to Barker's work on the nervous system for more com-
plete descriptions; still the insertion of a diagram, especially of
the cochlear nerve, or a more definite statement of the relations
of the various parts, might have made such reference unneces-
sary. We believe that some improvement could still be made
in the way of rendering the work more useful to medical
students. Thus the treatment of aphasia, a subject of consider-
able interest in itself and besides of some clinical importance,
is rather brief, while to the growth of the brain probably more
sjiace is devoted than its importance to the medical student calls
for. The subject is carefully brought up to date by the addition
of most of the recent work, such as that of Nissl and Marinesco.
A large amount of material has been drawn from Barker's
compendium, " The Nervous System and its Constituent Neu-
rones."

Professor Bowditch's article on the sense of vision is prac-
tically unchanged. The only real additions made are included
in the two paragraphs which emobdy the views of Miiller on
color perception and Einthovin's explanation of the illusion of
space-perception. The author takes advantage of the new edi-
tion to insert many references that were omitted in the first
edition. These might be still further improved by the addition
of dates. As far as style, appropriate selection, and coordinate
treatment are concerned, there is nothing that could be wished
for.

The articles on the remainder of the " special senses," in
which are apparently included the senses of hunger, thirst and
equilibrium, are contributed by Professor Sewall. With the
exception of slight alterations in the articles on hearing, cuta-
neous and muscular sensations and equilibrium necessary to
bring them up to date, these articles stand as they were in the
first edition. The anatomical expositions are excellent, the style
clear, and the subject-matter as complete as the limitations of
a text-book permit.

The fact that under the physiology of the " Special Muscular
Mechanisms " only the physiology of locomotion and of the voice
and speech are developed, might influence the beginner into
believing that these are the only special muscular meclianisms.
A brief reference to the special mechanisms treated in other
parts of the work might have freed it from this ambiguity.
The articles under this head by Lombard and Sewall call for
no special comment.

The fascinating article of Lee on reproduction has been kept
up to its original high ])lane by the addition of the recent
literature. Thus Schenk's views on the determination of sex
receive an approjiriate notice, and Arrhenius' interesting sugges-
tion that the rhythmicitj' of menstruation might possibly be
dependent upon synchronous variations in atmospheric electric-
ity is referred to. A few loose statements from the first edition
have crept into the second, e. g., " the thickness of the spermato-
zoan is .055 mm.," " the number of chromosomes in the chroma-
tin," " the most abundant of the solid chemical constituents
of the spermatozoan is nuclein, probably in the form of nucleic
acid."

JULT, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

225

So much for the text-book so far as the individual contribu-
tors are concerned. The advantages and disadvantages of a
text-book written by a number of authors are obvious and have
been fully and frequently discussed. The advantages in this
special case have been well brought out in the review of the
first volume of this text-book above referred to. One of the
disadvantages (arrangement) was also then mentioned. Beside
disadvantageous arrangement, omission is quite apt to occur.
Every attempt has apparently been made to guard against this
in the work under consideration. The only omission of any
importance that the reviewer has discovered is a treatment of
the knee-jerk phenomenon. Donaldson, in sjieaking of nervous
background, mentions reinforcement of the knee-jerk, appar-
ently taking it for granted that this subject has been treated
by Lombard. Lombard, however, says nothing about it, prob-
ably believing that it does not come within his sphere. The
text-book is thiis minus a discussion of this important phe-
nomenon, which is so much the more to be regretted when we
recall the fact that one of the contributors (Lombard) has
devoted so much of his time to the investigation of this very
point.

It is to be distinctly understood that the unfavorable criticisms
herein mentioned involve only minor points which may be found
in every text-book if looked for. Indeed one is struck by their
relative infrequency in the book under discussion. And after a
thorough perusal of the American Text-book of Physiology the
reviewer lielieves, as has been stated liy another elsewhere, that
'■ on the whole this work is certainly the best text-book of
physiology for medical students in the English language, and it
will doubtless continue to be used generally in all inedical
schools of the first class." J. E.

A Medico-Legal Manual. By William W. Keyser, Lecturer on
Medical Jurisprudence and Judge of the District Court,
Omaha. {OmaJui: Burkley Printing Co., 1901.)

This excellent little book has been written by the author for
the benefit of physicians and aims to present the legal side of
medical jurisprudence. It gives legal terms and principles with
the laudable iMir])Ose of preparing the medical man to acquit
himself creditably as an expert witness.

The author takes a most sensible view of the vexed question
of expert testimony. He says: " Much of the odium heaped on
opinion-evidence is chargeable to present methods of selecting
expert witnesses. Each side calls only those whose opinions are
preascertained and favorable. The witnesses are biased by a
desii'e for victory for the side which enlists them, particularly
so if the opposing exjierts are members of other schools of
practice. .Justice is thwarted, advance in medical science is
retarded and the profession is disgraced. It is not the province
of this work to advocate any particular method of procuring
expert testimony; but it is proper to urge the professions of
law and medicine to extricate this valuable branch of evidence
from its humiliating situati6n. Expert witnesses should be
called by the State or by the trial judges, not as friends or
supporters of either side, but as advisers of the court. Their
fees should be paid out of a general fund and should not depend
on the result of the case. Indeed, so far as may be, they shoulil
occupy a position as independent and impartial as that of the
judge or jury."

The chapter entitled " The Doctor as a Witness " is eminently
clear, practical and marked by good sense. It should be read
by every young physician.

The book as a whole is worthy of all praise. It is a manual
and not an exhaustive treatise, and cannot super.sede the classical
works on jurisprudence.

Golden Eules of Skin Practice. By David Walsh, M. D., Edin-
burgh. Golden Rule Series, No. VIII. pp. 102. (Rrutol :
John Wriyht d Co., 1000.)

A tersely written and convenient little manual for the treat-
ment of diseases of the skin. The directions given for the use
of remedies are sensible and judicious.

Urinary Diagnosis and Treatment. By J. W. WAiNwnir.nT, M. D.
(VhU-uyo: U. V. EnueUiurd & Co., WOO.)

In this small work of 134 pages, the author attempts to give
the simjilest methods of urine examination with the most recent
ideas concerning the treatment of urinary disorders. As he
states that he wishes to avoid the more or less elaborate accounts
of larger books, it is probably not proper to oifer any criticism
as to his descriptions exceirt on one important iioiut, namely,
clearness. The shorter such things are made the more necessity
for the absence of any doubt as to what is meant. For example,
the writer lays much stress on the recognition of the number
and kind of casts, and yet his description of them is at times
even ptizzling. Thus one might have some difficulty in knowing
what was meant by this: " If the epithelium be attached to the
tube and is discharged alone and after the epithelial cast, we
have the hyaline casts."

The busy general practitioner, for whom the work is intended,
would be better to consult a more elaborate manual for his
urinary work. The prescriptions, formulae of solutions and
tables along with the plates, which are from Hoffman and Ultz-
mann, will all be found useful. These, with the occasional notes
on treatment, are the best features of the book.

The American Year-book of Medicine and Surgery for IDOl. In
two volumes. Vol. I. General Medicine. Vol. II. General
Surgery. {Phiiudelphia a>nd London: W. B. SiimHkr.f <G Ci>.,
1001.)

The division of this work into two volumes, which was begun
last year, has proved so satisfactory that it is continued. The
smaller volumes are much more easily handled. There is little
to be said of the Year-book except to repeat our previous com-
mendation of it. It has been found most useful aiul relialile.
When one considers the possibility of error in the handling of
so many references, the care taken in the preparation of the
articles must be evident. The Y'ear-book is worthy of the sup-
]iort of the profession. Dr. Gould and his contributors are to
be congratulated on the volumes for this year.

The Tale of a Field Hospital. By Frederick Treves, (hoiuhjii
and New York: Cassrll d- Co., 1000.)

We have long known with what a graphic pen Mr. Treves can
write of disease and its manifestations. He has shown in the
present work that he can equally well describe places and events.
This is a small volume, very neatly gotten up and illustrated by
excelTent photographs. It gives the account of the field hospital
with Buller's force, with which Mr. Treves was connected. The
chapters show the clear-cut description which has been such a
feature of the recent work of war-correspondents. The text is
not specially professional in tone, there are no technical descrip-
tions, and yet throughout one feels that the eyes by the help of
which we see are those of one of our own profession.

It is impossilde to quote much of the contents. The sombre
note must predominate in the account of a field-hospital. Per-
haps the chapter on "The Two White Lights" is the best ex-
ample of this. The situation of the hospital was marked at
night by two white lights on a flagstaff, and one can imagine
what the sight of them meant to the wounded who were being
brought in. The query of the wounded man in the bottom of

226

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 12i.

tlie ambulance sums it up: " Don't yovi see notliing- yet, Bill, of
the two white lights? " The other side is not lacking, as is
shown in the chapter on " Tlie Body-snatchers." This name
was given to a volunteer ambulance corps of two thousand men
recruited from everywhere but who seem to have done excellent
service. They became the butt of many jokes and were linown
as " body-snatchers," " catch-em-alive-ohs " or the " pick-me-ups."
The constant habit of the " tommies " is to turn everything' into
a jest.

Mr. Treves has i)aid close attention to the feelings and senti-
ments of the common soldiers. He bears testimony everywhere
to his courage and patient endurance. Little is said in reference
to the hospital management, yet one gathers that the author
considers tlie best possible to have been done.

The Medical Annual. A Year-book of Treatment and Practi-
tioner's Index. (1901. BriMol: John Wriyht d- Co.; 2icw York:
E. B. Treat, d Co.; Toronto: J. A. Caweih d Co.)

This is the nineteenth year of this annual and the standard of
previous years is well kept up in the present volume. There are
now seven contributors from this side of the Atlantic. The title
explains the purpose of the book. It is divided into sections, of
which the first deals with the new remedies of the year. The
author in his introduction alludes to the decline in the art of
prescribing and quotes the remark that " with some practition-
ers the atrophy of disuse has almost blighted their capacity to
think out and indite a good prescription." We would rather
suppose that in many of the younger generation such a capacity
has never existed. Thei'e is a good article on toxins and anti-
toxins in this section. By far the greater part of the book is
taken up with the discussion of new treatment. Subjects are
taken up alphabetically, the principal articles on the subject are
extracted and the list of references given. It is impossible to
review such numerous articles, but those on the digestive system
and heart seem especially good. Throughout, however, the work
has been well done. The third section includes sanitary science,
recent legal decisions of interest in medicine, a review of new
inventions and appliances, and a list of the new books of the
year, medical journals, etc. This volume can be recommended
as previous ones to be of much use, especially to the busy prac-
titioner.

Tropical Diseases. A JIanual of the Diseases of Warm Climates.
By i'ATiucK Manson, M. D., LL. D. {London und Xcw York:
Ca^sell d Co., I'JUO.)

This is a revised edition of this work, which has now grown
to nearly 700 pages. The small size renders it very convenient
for carrying, a point kept in view in the preparation of the
volume. The book opens with the consideration of malaria, to
which considerable space is given. The part played by the mos-
quito is fully described and illustrated by diagrams. The dis-
cussion of the disease is thorough as might have been expected.
The section on haemoglobinuric fever is especially interesting.
Yellow fever, Bubonic plague and various rarer diseases are
next considered. The account of beriberi is given in a graphic
way, and the description of the disease is excellent. In taking
up dysentery, Dr. Manson points to the probability of what has
more recently been practically established in regard to the
various factors in the causation of the disease. Abscess of the
liver is discussed at some length. Perhaps the most interesting
section is that on animal parasites and associated diseases.
Regarding filiarisis especially. Dr. Manson is well qualified to
speak, and this is a most valuable portion of the work.

There are few works on medicine that can be read with more
pleasure in addition to profit than this one. One reads not only
for the interest of the subject, but also for the style of the

writing. It is to be regretted that this is not a characteristic
of more medical works.

A Pilg'rimage; or the Sunshine and Shadows of the I'liysician.
By Wm. Lane Lovvdbr, B. S., M. D. (Louisoillc, Ky.: It. H.
Carotlwrs.)

This little volume is the outgro\\ th of a series of essays read
before several county medical societies in Kentucky. The inten-
tion of the book is to dignify and ennoble the profession of
medicine. The sentiments contained in it are unexceptionable
but commonplace. They are enforced by trite quotations from
familiar poets, living and dead. The following from the first
page will serve as an example of the one hundred and ninety
pages which follow:

" The career of the physician begins with his determination to
study medicine and terminates with his death; or, as is so beau-
tifully portrayed by the immortal Gray in that matchless poem
■ The Rude Forefathers of the Hamlet,' when

' The breezy call of incense breathing morn.

The swallows twittering from the straw-built shed.
The cocks shrill clarion or the echoing horn
No more shall rouse them from their lowly bed.'

Then it is, and not till then, that his labors cease and his trials
are all ended. The morning of this life should be commenced
with aseptic hands and a sterilized heart, that the ambition to
realize the ideal in a profession, honored in all ages by all men,
will not be infected by skepticism or greed."

If one has time to read these excellent but thread-bare senti-
ments he will surely receive no damage. The question, however,
obtrudes itself whether it is worth while for the author to
spend " the dark and silent hours of the night — hours stolen
from sleep; hours usually allotted to the repose of body and
mind " — in writing them, as we are assured he has. The pur-
Ijose of the book is good.

Nursing- Ethics for Hospital and Private Use. By Isabel Hamp-
ton IvOBB. (Clccclund: J. U. Havayc, ilU-92 ^Vood litncl, I'JUl.)

While books ou the subject of nursing are rapidly increasing
in number and variety, this is the first attempt in this country,
so far as we know, to deal with this subject from any but the
practical and technical standpoint. In the twelve chapters of
which- the book is composed we find first the subject of nursing
as a profession thoroughly discussed, and supplemented by a
careful consideration of what should constitute the qualifications
of those who desire to enter it. The duties of the nurse as a
pupil and as an officer in every condition of hospital life follow;
aud her relation to the public generally is treated exhaustively
in the later chapters, the two last taking up the subject of
private duty in a clear, comprehensive and satisfactory manner.
The book is in fact a treatise ou the whole duty of the nurse,
and while we cannot follow in detail the handling of the many
points brought forward, we can recommend the book as valuable
and suggestive, not only to the individual nurse, but to superin-
tendents and teachers in training schools as a medium for syste-
matic instruction. In view of the fact that nursing is pre-
eminently one of those occupations in which professional skill
should always be supported by personal attributes of a very high
and definite order, it might seem surprising that this book is
the first of its kind were it not from the fact that it is generally
believed that these qualities are inborn and the principles which
underlie them cannot be taught through the medium of books.
In the training of character, however, which is one of the fore-
most objects of all modern education, one gladly recognizes
as the most helpful agencies much which is out of the beaten
track of definite instruction, practical or theoretical, and which
helps by guiding and suggesting.

July, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

227

Whatever the autlior writes about nursing- must be accepted
as the work of one thoroughly conversant with every aspect of
her subject, and as the subject itself is one which occupies a
fair share of ijublic attention, the book must have a wide
influence.

Diseases of the Tong-uo. By Henby T. Butlin, F. E. C. S., 1). C. L.,
Surgeon to St. Bartholomew's Hospital, formerly ICrasnius
Wilson Professor of I'atholog-y and Hunteriau Professor of
Surgery at the Royal College of Surgeons; and Walter G.
Spencer, M. S. M. B. (Lond.), F. R. C. S., Surgeon to the
Westminster Ilospital and in charge of the department of
diseases of the nose and throat, formerly Erasmus Wilson
Professor of Pathology at the Royal College of Surgeons.
Pp. 475, illustrated with eight chromolithographs and thirty-
six engravings. (New York: C<i.sseU li Co., Liiiiilml, 1000.)

In the tweuty-two chapters of this volume are contained in
concise form the essential facts with regard to the anatomy of
the tongue, all of its usual and unusual diseases and the various
methods of treatment, operative and otherwise, which have
been undertaken for these affections. The first chapters are
devoted to the anatomy of the tongiie, congenital defects and
inflammatory and other benign affections of the tongue. In dis-
cussing the appearances of the tongue under various conditions
and the method of their production, Butlin expresses his belief
that the results of everyday observations are still exti-emely
indefinite, in spite of the fact that from the earliest times
onward attempts have been made to collate the signs exhibited
by the tongue with particular diseases as distinguished from
constitutional states and to make the tongue serve as an aid in
the diagnosis of disease. The tongue is in no way a trustworthy
mirror of alterations in the mucous membrane of the intestinal
tract. Tuberculosis and syphilis of the tongue and the rarer
forms of diseases are thoroughly discussed and will be consulted
by all who are S])ecially Interested in these subjects. For the
general surgeon the chapters dealing with carcinomata will be
of greatest interest. Butlin is not disposed to place much im-
portance on predisposing causes of cancer such as syphilis, gout
and hereditary tendencies, but exciting causes, particularly
irritation by rough and carious teeth, ill-fitting tooth plates and
frequent smoking with the rubbing of the stem of the pipe upon
the surface of the tongue are thought to have much to do with
the causation of carcinoma. Especial stress is laid upon the
application of caustics: "If there be one thing more harmful
than another in the treatment of simple and indolent sores and
affections of the tongue in persons over thirty years of age it
is the application of a strong caustic." The diseases most
likely to be mistaken for carcinoma in making a diagnosis are
sj'philitic lumps and sores, tuberculous ulcers, simple warty
tumors and simple ulcers and fissures. The resemblance which
each one of these diseases at times bears to carcinoma is so
great that the difficulty of deciding on the exact nature of the
affection is extreme. The therapeutic test is of importance in
syphilis, and in cases of doubt it is recommended that a portion
of the ulcer should be cut out and examined microscopically.
In operating for carcinoma the complete excision with removal
of the glands of the neck is favored. The diseased area together
with % inch of apparently healthy tissue around it in every
direction should be rcmoied. As to the importance of removal
of the lymphatic glands of the neck, Butlin states that out of
102 patients operated upon, no fewer than twenty-eight had
recurrence in the lymphatic glands without recurrence of the
disease in situ. The mortality for uncomplicated operations is
estimated at scarcely 7 per cent, but it rises to more than 20
per cent for excisions below the jaw and to 35 per cent for
operations which are complicated by removal of part of the

lower jaw. The number of permanent cures is estimated fi'om
a study of statistics at about 'JO per cent, but there is thought to
be every reason to hope that this percentage, which is still very
small, will be greatly improved in the future. At the same
time it is probable that carcinoma of the tongue will always
remain a very deadly disease. There is api^ended an extensive
bibliography, classified under various headings, covering twenty-
four pages.

This book is generally recognized as the most autlioritative
monograph which has appeared on this subject. It is indis-
pensable for the library of the general surgeon and will prove
an important addition, containing many valuable and interest-
ing facts for the library of the general practitioner.

The Thirty-first Annual Report of the State Board of Health.
(Boston: WrigJit cG Potter, 1900.)

This report covers the operations of the Board for the year
ending Sept. .SO, 1S99. Dr. H. P. Walcott and Dr. S. W. Abbott
continued as president and secretary respectively, positions they
have held for many years. There were no changes amongst the
other members.

The General Report calls attention to the increased mortality
in recent years throughout Massachusetts from local diseases
(i.e., of brain, heart, lungs, kidneys, etc.), but this increase is
more than counterbalanced by the decrease in deaths from
infectious diseases, so that the total death-rate shows a diminii-
tion; thus, with an average death-rate for fifty years of 19.5
deaths per 1000 living, the death-rate for 1899 was 17.4.

Smallpox. — There were 105 cases during 1899. From 1883 to
1899 there were 525 cases. Thus one-fifth the total number for
these seventeen years occurred in the last year. Since 1885, the
fatality (proportion of deaths to cases) was 26 per cent amongst
the unvaccinafed, 7.6 per cent amongst the vaccinated. Of those
attacked by the disease, roughly one-half had been vaccinated;
but about half of these had been vaccinated in infancy only.
Further interesting details are given p. xvii.

TyplmUl fetter. — The death-rate continues to show a steady
diminution.

Consiimptimt. — The death-rate for the five-year periods from
1851-55 to 1891-95 shows a gradxial and fairly steady decrease,
from 41.1 per 10,000 living in the former period to 2r!.l in the
latter. In 1896 the rate was 21.7, dropping steadily to 18.7 in
■5899.

Diplitlieria.— From 1891 to 1895 the death-rate per 10,000 living
fluctuated from 5.3 to 7.4, the fatality varying from 18.9 to 31.7.
From 1896 to 1S99 the death-rate fell to 2.6 in 1898, rising again
to 3.7 in 1899. The fatality steadily diminished from 15.1 in
1896 to 11.5 in 1809.

Isolation linspxtals. — This most important factor in the pre-
ventive control of infectious diseases is becoming prominent in
Massachusetts, one-third of all the cities having provided them-
selves with hospitals for diphtheria and scarlet fever since 1890.
Twice as many cities, however, have provision for smallpox
patients, although smallpox is far less common. Not only are
these hospitals valuable from a therapeutic standpoint, but the
isolation of the patient in them is very much more efficient than
it can be at home, and much trouble and expense to the family
resulting from the rigid quarantine regulations in force when
the patient remains at home are avoided. No question in
public health is more pressing than the insuring of the maxi-
mum care for infectious patients at the minimum cost in time,
trouble and cash to the family. The isolation hospital seems
to be the one solution.

Increase of cancer. — The death-rate per 10,000 living in 1856
was males, 1.29; females, 2.45. In 1895, a practically unbroken
record of increase ended with death-rates of 4.40 for niales, 9.44

228

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 134.

for females. While it is probable that greater accuracy in
diagnosis accounts for part of this increase, the subject has '
been eonsitlcred by the Board worthy of an investigation, which
has been entrusted to a commission of pliysicians who are to
report later.

Paris Ex/mslliuii.— The secretary of the Board, Dr. S. W. Abbott,
was invited by the Director of the Department of Social Econ-
omy, Education and Hygiene of the United States Commission
to prej^are a monograph on the progress of hygiene in the
United States and to collect an exhibit of subjects i^ertaining
to public health throughout the United States. This exhibition
received a " Grand Prix." A gold medal was awarded to Dr.
Abbott also in appreciation of his successful work in the matter.

WfMcr supply and sewerage. — The work of the Board in these
lines is best shown by a brief review of the main divisions. In
1899, seventy-nine official applications were made to the Board
for advice on these subjects, this being the largest number in
any year since the Board was established. After the necessary
hearings, etc., appropriate action was taken. Chemical and
microscoiiic examinations were made from 212 different sources
of water supply, involving some 3500 analyses.

About 90 per cent of the population of this State live in
districts having a public water supply. Only two towns with
more than 3500 population are unprovided. Of the total popula-
tion supplied, ten-elevenths receive their water from supplies
publicly owned, the remaining one-eleventh from supplies owned
l)y private companies.

By an unfortunate omission, the Acts of 1897, which author-
ize the State Board to make rules and regulations regarding
pollution and to enforce the same, make no provision, in the
absence of special legislative appropriations, for the payment of
bills so incurred. Thus the action of the Board is unduly
hampered.

Sutnmcr resorts. — One hundred and thirty or more exist
throughout the State. The sanitary conditions of some of these
were far from ideal. It has been a matter of remark in Boston
for some years that the typhoid fever cases increase in number
as soon as the tide of population turns cityward in the autumn,
due in part at least to infection during the summer vacation.
This factor is an unusually prominent one in Boston because
the average wealth is high and with it corresponds the size of
the summer exodus.

Under Watrr Supply Statistics, the table on p. 401 showing the
water consumption of the various towns and cities, illustrates
again the fact that the per capita consumption in districts of
large population is greater, as a rule, than where the population
is small.

LoAOrence E.vpcrimental Station. — During 1898, many new inves-
tigations were begun under H. W. Clark on methods of purify-
ing .sewage at high rates of filtration. These were continued
during 1899, with additional experiments based upon new points
of practical interest developed during their study. The more
important of the older intermittent sand filters have been con-
tinued in operation. The sejitic tank has received much atten-
tion. Bacterial or contact filters and the use of coarse filtering
materials — broken stone, etc. — have been studied.

The treatment in the septic tank of sludge alone was sug-
gested by the observation that the percentage of removal of
organic matter increases with the strength of the entering
sewage. In September, 1899, the investigation of this subject
was begun. The supposed necessity of using a closed tank (to
secure the exclusion of light and air) was shown a fallacy, since
in the open tank air and light is excluded by the bacteria and
fatty scum which form at the surface of the sewage. About
two months were required for a septic tank to become fully
active, the gas evolved measuring thereafter about 41/, per cent
by bulk of the sewage treated. This gas is largely methane and

nitrogen with small quantities of carbon dioxide, carbon mon-
oxide,' oxygen and " heavy hydrocarbons." One value of the
septic tank treatment, as a preliminary to filtration, lies in the
destruction it ensures of the carbonaceous matters (cellulose,
paper, etc.) to which the clogging of sewage filters is largely due
in the absence of such treatment.

Some interesting work on the removal of B. coli from water
by sand filters is given. The bacterial efficiencj' of a filter is
generally supposed to be an index of the protection it affords
in the removal of typhoid bacilli, should these exist in the
applied water. The percentage of removal of B. coli — used in
this instance as a substitute for the more diificult typhoid
bacillus — does not, however, always correspond with the bacterial
efficiency; thus, for certain months, the applied wa'ter at the
city filter was examined both for total bacteria per cc. and for
number of B. coli per cc. The effluent was also similarly
examined. The results ran as follows:

Total haet.
1809. inapplieil
water.

Jau. 4900
Feb. 5900
Mar. 6300

R. coli in
applii'd
water.

38
31
19

Total bact.

in effluent

water.

108

% of times

Bacterial B. citli 00- " B. coli

eliiciency. curred in elKciency.'

effluent.2

98.31
98.17
99.30

54^

98.08
98.00
99.60

The last co'umn of the above table was calculated by the present writer
from the data given. The other figures are Mr. Clark's.

It would seem from the above that the eificiency of a filter
for B. coli lessens more quickly as general bacterial etficieney
drops than does this general efficiency itself, but still more
striking is the other fact pointed out by Mr. Clark that, within
the narrow play of 1.13 per cent variation in an efficiency never
below 98.17, the variations in the frequency of presence in the
effluent of B. coli (and by inference in the frequency of pres-
ence of typhoid bacilli were they present at all) are very
marked.

Mr. Clark also contributes a paper on iron in ground waters.
After discussing the various methods for its removal and illus-
trating- each by experiments made on various Massachusetts'
supplies, Mr. Clark concludes that different iron-bearing waters
may require different methods of treatment for satisfactory
purification.

Food and drug inspection. — The annual expense of the food and
drug inspection increased from about $3000 in 1SS3 to over
$11,000 in 1899. The number of samples examined, however,
increased from about 1300 in 1883 to about 9800 in 1899, so that
the expenditure per .sample, as the report points out, decreased
almost one-half.

The milk inspection was devoted mainly to the supervision of
dairies, since the local milk inspectors of the various municipali-
ties, while controlling the milk .supply after it reaches those
municipalities, have no jurisdiction over the sources of origin
outside.

The number of prosecutions for adulteration diminished from
150 in 1891 to 47 in 1899 on account of (1st) the reduction of the
legal standards of purity or strength; (2nd) the fact that in-
spectors whose business it is to collect samples gradually become
known to the dealers, and it therefore becomes increasingly
difficult for them to secure adulterated samples; (3d) the growth
of local inspection; (4th) the efforts of the Board to go behind
the often innocent retailers to reach the guilty producers, who
in many cases reside outside of Massachusetts, which is a manu-
facturing and not a food-producing State; (5th) the actual im-
provement in the quality of foods placed on the market.

■ Prof. L. P. Kinnicult states as the result of receot investigations that the
gas recorded as carbon monoxide gives certain carbon mono.vide reactions,
but is not carbon mono.xide. Its iclentity has not yet been determined.

- Each time B. cult was found, not more than one colony per cc. was probably
present.

July, IDOL]

JOHNS HOPKINS HOSPITAL BULLETIN.

229

The report of the analyst, Albert E. Leach, is particularly
v:iluable this year, since it ^ves the methods of analysis used.
There are comparatively few food and drug experts in this
country, but the ways in which adulterations are detected should
be of interest to all consumers as well as to those scientifically
inclined. It is true that the publication of the methods of
analysis may atTord to keen-witted, would-be adulterators sug-
gestions for new ways of " beating the game," but it is the
business of the expert to so conduct his investigations that he
cannot be deceived. However keen the adulterators may be, the
expert has the greater weight of scientific knowledge and
experience behind him. Moreover, " thrice is he armed who
hath his quarrel just."

Experiments on the solvent action of fruit acids ou tin, bear-
ing upon possible ijoisoning from canned goods, showed that
most of the solution occurs in the first three mouths. The
percentages of tin taken up by ditferent strengths of ditferent
acids were determined. •

An ingenious device for the deception of the public is that
practiced by a certain baking powder concern, which advertises
■■ All grocers are authorized to guarantee bread, etc.," made
with this powder free from alum, ammonia, etc. It is to be
noted that no claim is made that the powder is free from these
substances; indeed, as a matter of fact, it contains both alum
and ammonia, but the advertisement is true to the extent that
in the preparation of bread, etc., the alum is converted into
aluminum hydrate and the ammonia is driven off!

In the collecting of samples of drugs, lists of the articles
wanted were furnished to various druggists. In some cases
they interpreted these lists as prescriptions, so tluit the analyst
received rather startling mixtures of such incompatibles as
liydrobromic acid, silver nitrate and bicarbonate of soda!

I'athuliigical and Bacteriological Lahoratory.— Since 1895, Br.
Theobald Smith has manufactured from 65 million to 75 million
units of diphtheria antitoxin. The strength of this antitoxin
has varied from 200 to 400 units per cc. T^he amounts used per
case are shown in a table on p. 057, reaching over 100,000 units
for one patient in one instance. The total fatality of cases
treated for five years is 11.2 per cent.

A summary of the diagnostic work of the Board follows and
the volume ends with Statistical Summaries and condensed reiMrts
from the different cities and towns of the State.

Amongst the latter are some interesting accounts of typhoid
epidemics traced to their sources, so far as was iJossible, by Dr.
F. L. Morse, Medical Inspector of the Board. (See pages 7;i7, 744,
754, etc.) In one of the epidemics described (p. 7(il) the infection
was very clearly shown to be carried by celery which had been
manured with undisinfected typhoid feces.

The impossibility of reaching an absolute decision as to the
source of infection in the majority of typhoid epidemics is well
illustrated by some of these accounts and should impress every
one with the importance of reporting every epidemic in which
the source may be indubitable, that the bulwarks of our faith
in these matters may be duly strengthened from time to time.
Too often it hai)pens that the expert is called in so long after
the source of infection has disappeared that only very tangled
threads of evidence remain and the Scotch verdict of " not
proven " must frequently be the sum total attained by prolonged
and conscientious work. It is better to render such a verdict
than one, which, while more definite in terms, is based upon
evidence not wholly conclusive.

It is difficult to discriminate between the successive yearly
reports of the Board, since all have been so excellent, but it
is true that from a technical standpoint the present report
will be of more interest to laboratory men than arc those of
the two or three preceding years. Particularly is tliis true of
the reports, already briefly outlined, from Mr. Clark and Mr.

Leach. The material oi the latter's report recalls somewhat
those earlier days when methods of analysis received treatment
so instructive that the publications of the Board really formed
technical text-books of a high order.

We must again regret the absence of other than a merely
formal contribution from Dr. Theobald Smith. Indeed all the
few faults of this report are those of omission, not of commission.
Needless to say the typography is, as usual, above reproach.

HlBBEET WiNSLOW HlLL.

Practice of Medicine. A Text-book for Practitioners and
Students, with Special Reference to Diag'nosis and Treat-
ment. By James Tyson, M. D., Professor of Medicine in the
University of Pennsylvania, and Physician to the Hospital
of the University. Second edition, thoroug-hly revised and
in parts rewritten. With 127 illustrations. (I'liiladelphia:
P. Blakiston's Son <& Co., 1900.)

The first edition of this admirable text-book appeared in 1896.
It was miost favorably reviewed in this journal in June, 1897.
The second edition has been thoroughly revised and in part re-
written. This has been done with only a moderate increase in
the number of pages of printed matter, the present edition con-
taining 1222 pages. The revision has been largely made in the
sections on infectious and nervous diseases. The section on
Diseases of the Nervous System has been revised by Dr. William
G. Spiller, which is sufficient guarantee for its having been
thoroughly done and for the subject being brought up to date.
We should like to have seen the subject of Neurasthenia dealt
with more fully, however. Only three pages are devoted to it,
which seems entirely insufficient considering the prevalence of
the affection. There is probably no atfection that the general
practitioner ai^preciates or understands less, nor is there one,
the treatment of which, gives him more annoj-ance and worry.

We occasionally observe that a recent clinical finding of im-
portance in the symptomatology or diagnosis of a disease has
escaped the notice of the author. For instance, we may call
attention to the fact that no mention is made of the marked
eosinophilia which is present in the acute stages of nearly all
cases of trichinosis. This is one of the most valuable observa-
tions on the blood in any disease in recent years, and has been
the feature that has attracted the attention of the observer to
the i^ossibility of an infection with trichinae in so many of the
recently reported cases.

In nearly every respect, however, the book is an admirable
one. We know of no text-book on the practice of medicine that
is more profusely illustrated by charts and plates. We jirediet
for it the same success that attended the publication of the first
edition.

Introduction to the Study of Medicine. By G. H. Roger, Pro-
fessor Extraordinary in the Faculty of Medicine of Paris.
Authorized translation by M. S. Gabriel, M. D. With addi-
tions by the author. {New York: D. Appleton d Co., 1901.)

This is in every way a most admirable book. It is based ou
a course of lectures delivered by Dr. Roger at the University of
Paris during the session of 1897-98. The translator has done
students and practitioners in this country a great service by the
publication of this edition in English. The volume has been
brought up to date by additions and corrections made by the
author.

The work, which contains 545 pages, is in no sense intended to
take the phice of a text-book on the practice of medicine. The
various disea.ses are not treated in detail, but the object has been
to give the student who is just entering the practical stage of
the study of medicine a thorough and broad understanding of
the general princiijles which underlie disease. The object of the
author will be apiireciated best by quoting the following lines

230

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 124.

from his preface: "We all kuow from experience how mucli
time is wasted by not knowing with what subject to begin, what
books to read, and also by being compelled frequently to refer
to a dictionary for an explanation of technical terms encoun-
tered. With the view of- relieving beginners of much useless
embarrassment, the Faculty of Medicine intrusted me with the
course of lectures which I now publish."

The first seven chapters are devoted to a description of how
an individual becomes sick. The causes are considered under the
heading of mechanical, physical and animate agents. Under the
latter he takes up the general bacteriology of disease. He then
I^roceeds to show how infection of the human organism takes
place.

The sections devoted to disturbances of nutrition, heredity
and inflammation are of unusual interest. We know of no text-
book in which the important problems connected with heredity
are presented so thoroughly and in so interesting a manner.

The author emphasizes the importance of careful observation
of the case under treatment, and the proper interpretation of
the conditions and physical signs found. Tlie cha^jters on sem-
eiology are of great value to the student in teaching him the
proper method of observing and examining a patient. The book
concludes with chapters dealing with the general considerations
which should guide one in making a diagnosis or prognosis of
a case and in outlining its treatment.

This book will be found of great service not only to the begin-
ner, but also to the advanced stiident in medicine, as well as to
practitioners. We know of no book of its kind in English. It
is filled with practical points which are not found in the ordinary
text-books of medicine. The book makes interesting reading
and the translator has apparently done justice to the original
edition.

Medical and Surgical Reports of the Boston City Hospital.
Eleventh Series. Edited by Herbert L. Burkell, M. D.;
W. T. Councilman. M. D., and Charles F. Witiiington, M. D.
(Boston: Pumglic'd hi/ tlie Trustees, 1900.)

The volume of the Reports of the Boston City Hospital for
1900 contains twenty separate papers on medical and surgical
subjects, with a total of 254 pages. A special appropriation has
enabled the editors to illustrate the reports this year. There
are several papers of especial interest, only a few of which can
be referred to in this review.

Lund reports six cases of acute hfemorrhagic pancreatitis from
the standpoint of the surgical treatment. Five of the cases were
in women, and four of these also had gall-stones. In no case
was a definite diagnosis made. Five of the cases were operated
on, with one recovery.

Jackson gives an analysis of 59 cases of malignant endocarditis.
In 43 cases the diagnosis was confirmed at autopsy. Cultures
were made in 23 cases, organisms being obtained in pure culture
in 19. The Streptococcus pyogenes was obtained in 8 cases,
pneumococcus in 5, Staphylococcus aureus in 3, Colon bacillus
in 1, Staphylococci and Streptococci in 1, Streptococcus and
others in 1. The distribution of the lesion in the 43 cases was
as follows: Aortic valves, 9 cases; aortic and mitral valves, 10
cases; mitral valve, 1.^ cases: right side of the heart, 6 cases;
endocardium of ventricle, 3 cases.

Bottomley reports 28 cases of tuberculous peritonitis in which
operative treatment had been adopted. Cases were considered
recovered only when they returned well at least one year after

the operation. Of the series, 11 recovered; the same number
died. Two cases improved and 4 cases could not be traced.

Low gives the bacteriological findings in 100 cases of acute
appendicitis. The results were as follows: Streptococcus pyo-
genes (pure culture), 2; Streptococcus pyogenes or diplococcus
lanceolatus and Bacilhis coli communis, 61; Strciitococcus pyo-
genes and intestinal saprophytes, 15; Bacillus coli communis
(pure culture), 8; Bacillus coli communis and unidentified cocci,
13; Bacillus lactis aerogenes and Bacillus pyocyaneus, 1.

Thomas and Hibbard have an interesting paper on Heart
Failure in Uiphtheria. They think that one death in five from
dii^htheria is due to heart failure. The complicatiuii is more
frequent in cliildren than in adults, and occurs most frequently
in the second week of the disease.

Diseases of the Heart: Their Diagnosis and Treatment. By
Albert Abrams, A.M., M. D., (Heidelberg), F. R. M. S.
{Chicago: G. 1'. Eiiyclliard & Co., 1900.)

This little volume of 170 pages contains a fu7id of information
on cardiac diseases with a concise review of their symptoma-
tology, physical signs and treatment. The subject is rather
attractively presented. The author states that the book was
never intended to aspire to the dignity of a treatise on diseases
of the heart, but that the primary object was to make it useful
to the practical physician in the diagnosis of cardiac diseases.
The personal experience of the author is frequently met with
throughout the volume. Whereas we can hardly see the need
for such a compendium as this book is, it will no doubt be found
of material aid to the general practitioner who has not the time
to consult a more extensive treatise on the subject.

BOOKS RECEIVED.

Essentials of the Diseases of Cliildren. Arranged in the Form of
Questions and Answers. Prepared Especially for Stxi-
dents of Medicine. By William M. Powell, M. D. Third
edition, thoroughly revised by Alfred Hand, Jr., A. B., M. D.
(Saunders' Question-Compends, No. 15.) 1901. 12mo. 25!T
pages. W. B. Saunders & Company, Philadelphia and
London.

Atlas and Epitome of Labor and Operative Obstetrics. By Dr. Oskar
SchaefEer. Authorized translation from the fifth revised
German edition. Edited by J. Clifton Edgar, A. M., M. D.
With 14 Lithographic Plates in Colors and in 139 other Illus-
trations. (Saunders' Medical Hand-Atlases.) 1901. 12mo.
Ill pages. W. B. Saunders & Company, Philadelphia and
London.

Principles of Siirgmj. By N. Senn, M. D., Ph.D., LL. D. Third
edition, thoroughly revised. With 230 Wood-engravings,
Half-tones, and Colored Illustrations. 1901. Svo. xv + 699
pages. F. A. Davis Companj', Philadelphia and Chicago.

Atlas and Epitome of 0 pit thai moscopii and Ophthalmoscopic Diag-
nosis. By Prof. Dr. O. Haab, of Zurich. Authorized trans-
lation from the third revised and enlarged German edition.
Edited by G. E. de Schweinitz, A. M., M. D. With 152 Col-
ored Lithographic Illustrations. (Saunders' Medical Hand-
Atlases.) 1901. 12mo. 85 pages. W. B. Saunders & Com-
pan3', Philadelphia and London.

The Johns Hirpkins Hospital BiillcUns are issued monthlu. They are printed by TBE FRIEDENWALD CO.. Baltimore. Sitiijle copies may he procured from
Messrs. CVSHINQ A CO. and the BALTIMORE NE ITS CO., BaUlmnre. Subscriptions. $1.0O a year, may be addressed to the publishers, THE JOHA'S HOPKINS
PRESS, BALTIMORE single copies ivill be sent by mail for fifteen cents each.

July, IDOL]

JOHNS HOPKINS HOSPITAL BULLETIN.

231

THE JOHNS HOPKINS MEDICAL SCHOOL.

FACULTY.

Daniel C. Oilman, LL. D., Presiiient.

William H. Welch, M.D., LL. D., Professor of Pathology.
Ira Uemsen, M. D., P». D., LL. D., Professor of Chemistry.
William Oslek, M. D., LL. D., F. K. S., Professor of Medicine.
Henuv M. Huud, M.D., LL. D., Professor of Psychiatry.
William S. Halsted, M.D., Hon. K. R.O. S. (Loud.), Professor of Surgery.
HowAHi) A. Kelly, M. D., Professor of O yneooloff y .
Fra.nkli.v p. Mall, M.D., Professor of Anatomy.
John .L Aisel, M.D.. Professor of Pharmacology.

WiLt.iAM H. Howell, Ph.D., M.D., LL.D., Professor of Physiology and Dean.
William K. Uuooks, Ph. D., LL. D., Professor of Zoiilogy.
J. WmriuiKiE Williams, M. D., Professor of Obstetrics.
Wii.LUM D. Hooker, M. D., Clinical Professor of Pediatrics.
John N. Mackenzie, M. D., Clinical Professor of Laryngology.
Samuel Theobald, M. D., Clinical Professor of Uphthalmology.
Henky M. Thomas, M. D., Clinical Professor of Neurology.
J. WiLLUMS Loud, M. D., Clinical Professor of Dermatology.
T. Caspar Gilchrist, M. K.C.S., L..S. A., Clinical Professor of Dermatology.
Hknhy J. liERKLEY, M. D., Clinical Professor of Psychiatry.
William S. Tihyeh, M. D., Associate Professor of Medicine.
John M. T. Finney, M. D., Associate Professor of Surgery-
Ross G. Harrison, Ph.D., M. D., .\ssociate Professor of Anatomy.
William W. Kussell, M. D., Associate Professor of Gynecology.
Thomas S. Cullen, M. F!., Associate Professor of Ciyuecology.
Keid Hunt, Ph.D., M.D., Associate Professor of Pharmac(/logy.
Robert L. Randolph, M. 1)., Associate Professor of Ophthalmology.
Thomas IS. Futcheh, M. H., Associate Picilessor of Medicine.
Charles R. Hardeen, M.1>., iVssociate Professor of Anatomy.
Walteii Jones, Ph. D., Associate Professor of Physiological Chemistry.
.loHN S. liiLLiNOS, M. D., LL.D., Lecturer on the History and Literature of

Medicine.
Charles W. Stiles, Ph.D., M.S., Lecturer on Medical Zoology;.
Ale,\aniier C. Abbott, M. D., Lecturer ou Hygiene.
Robert Fletcher, M.R. C. S. (Eng.), M. D., Lecturer ou Forensic Medicine.

Joseph C. Bloodoood, M.D., Associate in Surgery.

Harvey Cushino, M. D., .\ssociate in Surgery.

Norman MacL. Harris, M.H., Associate in Llacteriology.

William G. MacOallum, M. D., xVssociate in Pathology.

Frank R. Smith, M.D., Associate in Medicine.

Hknry It. jAC(iBS, ^L D., Associate in Medicine.

Thomas McCrae, M. U., Associate in Medicine.

Eugene L. Opie, M. D., .Associate in Pathology.

Percy- M. Dawson, M.D., Associate in Physiology.

Stewart Paton, M. D.. Associate in Psychiatry.

Frank W. IjYNch, M. IX, Associate in tHjstetrics.

Hugh H. Youno. M. D., Instructor in Genito-Urinary Diseases.

Henry McE. Knower, Ph. D., Instructor in Anatomy.

Mehvin T. Sudler, Ph.D., Instructor in Anatomy.

CH.4RLES P. Emerson, M. D., Instructor in Medicine.

George Walkkh, M.D., Instructor in Surgery.

James F. Mitchell, M. D., Instructor in Surgery.

M.YCTtER Waheiei.I), M.D., Instructor in Laryngology.

Louis P. HA.MiuRiiER, M. D.. Instructor in Medicine.

Joseph EuLANiiEH, M. D., Instructor in Physiology.

A. R, L. DoHMK, Ph.D., Instructor in Pharmacy.

Thomas R. Urown, M.D., Instructor in .Medicine.

RUFUS I. Cole, M. I)., Instructor in Medicine.

William S. IIaer, M. D., Instructor in Orthopedic Surgery.

Elizabeth Hurdon, M. D., .Assistant in Gyneccjiogy.

Henry O. Reik, M. D., Assistant in Ophthalmology.

Harry T. Marshall, M. D., Assistant in Pathohjgy.

Warren H. Lewis, M.D., Assistant in .Anatomy.

John li. MacCallum, M.D., Assistant in Anatomy.

Humphrey W. Ducki.er, M.D., .\ssistant in Obstetrics.

Samuel A.mberg, M.D., Assistant in Pediatrics.

Nathan E. H. Iglehart, M. D.. Assistant in Surgery.

J. Hall Pleasants, M. D., Assistant in Medicine.

GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the Instruction of students October, 1893. This School of Medicine Is an In-
tegral and coordinate part of the Johns Hopkins University, and It also derives great advantages from its close affiliation with the Johns Hopkins Hos-
pital. The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the
middle of June, with short recesses at Christmas and Easter. Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital.
While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable
preliminary education and upon thorough training In the medical sciences. The first two years of the course are devoted mainly to practical work, com-
bined with demonstrations, recitations and, when deemed necessary, lectures. In the Laboratories of Anatomy, Physiology. I'hyslologlcal Chemistry,
Pharmacology and TcKicology, I'athology and Bacteriology. During the last two years the student Is given abundant opportunity for the personal study
of ea.ses of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for
thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout
the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives:

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree In this uuiverslty.

2. Graduates of approved colleges or scientific schools who can furnish evidence: (a) That they have acqnaintance with Latin and a good reaiUng
knowledge of French and German; (b) That they have such knowledge of physics, chemistry, and biology as is impaited by the regular minor courses given
In these subjects in this university.

The phrase " a minor course," as here employed, means a course that requires a year for Its completion. In physics, four class-room e.ferelses and
three hours a week In the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory iu each
subject.

3. Those who give evideuce by examination that they possess the general education implied bv a degree In arts or^ in science from an approved
college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.'

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the college or scientific schools where they have studied, as to the courses pursued In physics,
chemistry and biology. If such certificates are satisfactory, no examination lu these subjects will be required from those who possess a degree in arts or
science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school will be reijulred (1) to pass, at the
beginning of the session In October, the matriculation examination for admission to the collegiate department of the Johns Hoiikins University, (2) then
to [»ass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. H. degree lu this University,
aud Ci) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only lu very rare
Instances will applicants who do not possess a degree In arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING.

Applicants for admission to advanced standing must furnish evidence (1) that the foregoing terms of admission as regards preliminary training have
been fulfilled, (2) that courses equivalent iu kind and amount to those given here, preceding that year of .he course for admission to which application
Is made, have been satisfactorily completed, and (3) must pass examinations at the beginning of the session in October In all the subjects that have been
already pursued by the class to nhlch admission is sought. Certificates of standing elsewhere cannot be accepted lu place of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates In medicine. The attendance upon
these courses has steadily Increased with each succeeding year and indicates gratifying appreciation of the special advantages here afforded. With the
completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the
academic year than that hitherto selected. It is. however, believed that the period now chosen for this purpose is more convenient for the majority of
those desiring to take the courses than the former one. The special courses of instruction for graduates In medicine are now given annually during the
months of May and June. During April there Is a preliminary course In Normal Histology. These courses are In Pathology, Bacteriology, Clinical Micro-
scopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genlto-Urlnary Diseases, Laryngology
and Rhinology, and Ophthalmology and Otology. The instruction Is Intended to meet the requirements of practitioners of medicine, and is almost wholly
of a practical character. It includes laboratory courses, demonstrations, bedside teaching, and clinical Instruction in the ward.s, dispensary, amphitheatre,
and operating-rooms of the Hospital, These courses are open to those who have taken a medical degree and who give evidence satisfactory to the
several Instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated In some of the
practical courses is necessarily limited. For these the places are assigned according to the date of application.

During October a select number of physicians will be admitted to a special class for the study of the Important tropical diseases met with In this
region.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

HBGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.

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BULLETIN

THE JOHMS HOPKINS

Vol. Xll.-No. 125.]

BALTIMORE, AUGUST, 1901.

[Price, 15 Cents.

CONTENTS.

TLe Medicine and Doctors of Horace. By El'gene F. L'okdell,

M. D., 23S

A Historieal Note Upon Diptera as Carriers of Diseases — Pare —

Declat. By Howard A. Kelly, M. D., 240

The Fiftieth Anniversary of the Invention of the Opbtlialmoscope.

By Harry Friedenwald, A. B,, M. D., 243

The First Nephrectomy and the First Cholecystotomy, with a

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S. Bobbs. By .Martin B. Tinker, M. D., 247

Measurement of the External Urethral Oritice. By O. Brown

Miller, M. D., 2.51

Abstract: The Frequency of fiull-Stoues in the United States.

By Clelia Diel Mosuer, A. .M., M. D., 2.53

Tendon Transplantation. By Sidney M. Cone, M. D., 2.50

Proceedings of Societies :

The Johns Hopkins Hospital Medical Society, 261

Chorea with Embolism of Central Retinal Artery (Dr. Tuomas],

Ophthalmoscopic Appearances [Dr. Reik]; — Volvulus of
Meckel's Diverticulum with Recovery after Operation [Dr.
William J. Taylor, of Philadelphia] ; — Exhibition of Medical
Cases [Dr. McCrae] ; — Contribution to the Study of the Fre-
quency of Oall-Stones in the United States [Dr. Mosuer]; —
Diabetes Mellitus Associated with Hyaline Degeneration of the
Islands of Langerhans of the Pancreas [Dr. Opie]; — Carcinoma
of the Male Breast [Mr. Warfield] ; — A Curious Form of Peri-
toneal Tuberculosis [Dr. MacCallum]; — A Lipo-Myoma of the
Uterus, with Exhibition of Specimen [Dr. Knox] ; — The
Advances Made in Medical and Surgical Diagnosis by the
Roentgen Method [Dr. Charles Lester Leonard, of Philadel-
phia]; — Exhibition of Medical Cases. On Hemorrhage in
Chronic Jaundice [Dr. Osler]; — Typhoid Spine [Dr. Osler]; —
Intestinal Dystrypsia I Dr. J. C. He.m.meter] ; — Foetal Trans-
mission of Typhoid Fever [Dr. Lynch]; — Abscess in the
Abdominal Wall [Dr. Hunner].

Notes on New Books, 2ti.5

THE MEDICINE AND DOCTORS OF HORACE.

By Eugene F. Cohdell, M. D.

[Raul hefiirt the .h.hitx /fojikins Iluspitnl RMorical Club, November 12, 1000.)

In all ages of tlio world the doetor and his practice have
been the shuttlecock of the wits and satirists. That medi-
cine has not perished under these assaults must be ascribed
to the unlimited faith of the human mind and to the leaven
of good that even in the darkest period of its history has
been niinirled with its shortcomings and errors. In selecting
an author of the Augustan age as rejn'esentative of its sen-
timent and inspiration, none occurs to us with more con-
vincing readiness than the great wit and lyric poet, the satir-
ist of lioman manners and morals, the boon companion of
Augustus and his prime minister, whose name heads this
]iagc. What has Horace to say of the doctors and medicine
of his tlay ?

It is a singular fact that nowhere in all his extant writ-
ings is there a word of unkindness or ridicule of the pro-
fessors of medicine. Of few writers of his stamp could such

a statement be made. His allusions are always kindly and
breathe unfeigned respect and confidence. This will sur-
prise us the more, when we reflect upon the character of
the Eoman profession of his day, just emerging from ob-
scurity and chiefiy in the hands of slaves and foreign ad-
venturers, bent in most cases solely upon self-aggrandize-
ment. Writing to a friend,' he gives this advice: "If your
side or kidney should be attacked with an acute disease,
seek a remedy for the disease," or as Sir Theodore Martin
puts it : '

" If spasms of pain assail your sides or back.
Send for the doctor; set him on the track
The mischief's cause and cure upon the spot."

' Epist. I, 6, 28.
''Metrical translation.

234

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

In another place he says:' "If no quantity of water
would put an end to your thirst, you would tell it to your
physicians."

And again : ' " The false modesty of fools will conceal
ulcers rather than have them cured."

During the latter half of the poet's life his health was
poor, the first evidence of failure manifesting itself on the
journey to Brundusiuni, when he was 28, in an inflammation
of the eyes : " Here, having got sore eyes, I was compelled
to smear black ointment on them." ' He was also, like Vir-
gil, a martyr to weak digestion. It is probable also that he
had some affection of the chest, as in addressing his mis-
tress Lyce, he says:' "This side of mine will not always
be able to endure your threshold and the rain," and in
Epist. I, 7, 26, he speaks of his " noti forte latus."

He must, therefore, have been brought into frequent con-
tact with physicians in a professional way and it must be
considered indeed remarkable that no word of blame or re-
proach of them escapes him. Take the ease of the court
physician, Antonius Musa. Horace was in the habit of
spending his winters at Baiae, a beautiful seaside resort in
Campania, not far from Naples. Here were hot medicinal
waters, pleasant and wholesome, and a mild air. The
wealthy Eomans built their villas around and the brilliant
society of Eome was transported thither during the cold
weather. Horace never tires of singing the delights of
" watery Baiae."

" Baiae's waters fair

With liappy heart I hail." '
" No bay in all the world so sweet, so fair.

As may with Baiae, Dives cries, compare.""
" Should winter swathe the Alban fields in snow,

Down to the sea your poet means to go,

To nurse his ailments and in cosy nooks.

Close huddled up, to loiter o'er his books." '

Now imagine this small, frail, prematurely gray poet,
with his weak digestion, his sore eyes, his " non forte latus,"
and his nervous temperament, " one to whom warmth is
life," '" ordered by the medical autocrat of Rome, to give up
his dear Baiae and go to take the cold baths at Velia or
Salernum and this in midwinter. Ugh! he shivers at the
thought, and yet no word of reproach escapes him — he has
no thought of disobeying.

Horace also seems to reprobate ignorant handling of drugs
in the following quotation:

" Where is the man * * *
Who ventures to administer a draught.
Without due training in the doctor's craft?
Doctors prescribe who understand the rules,
And only workmen handle workmen's tools," "

or to use a literal translation (and more fully) :

" He that is ignorant of a ship is afraid to work a ship ;
none but he who has learned dares administer (even) south-

3 Epist. II, a, 46. "Epist. I, Iti, 24. » Sat. I, 5, 30. « Od. Ill, 10, I'.l.
'Martin, Od. Ill, 4, 34. s Martin, Epist. I, 1, S3. 'Martin, Epist.
I, 7, 10. '"Epist. I, 30, 24. " Martin, Epist. 11, 1, 114.

crnwood to the sick; physicians undertake what belong to
physicians; mechanics handle tools, but we learned and un-
learned, promiscuously write poems."

Horace, evidently speaking from his personal experience,
inculcates a sparing and plain diet. To his friend, Iccius,
he says : '"

"Si ventri bene, si later! est, pedibusiiue tuis, uil
Divitiic poterunt regales addere majus,"

or, as Theodore Martin translates it:

" Let your digestion be but sound,
Your side unwrung by spasm or stitch,
Your foot unconscious of a twitch.
And could you be more truly blest.
Though of the wealth of kings possessed ? "

This definition of health corresponds nearly with the
soundness of " limb, wind and pizzle," which traders in
horses are used to demand.

The word medicus occurs nine times in the writings of
Horace. Addressing an imaginary raiser, in Satire I, 1, 80,
he says : " If your body should become disordered by being
seized with a cold, or any other casualty should confine you
to your bed, is there any one upon whom you can rely to
stay with you, prepare the fomentations and beseech the
doctor to bring you back to health and restore you to your
children and dear relatives ? " This passage recalls a letter
written by Cicero to his learned freedman. Tiro, in which
he urges the invalid to spare no expense — " another fee to
the doctor may make him more attentive." "

Opimius, another miser, who thinks himself poor, although
surrounded by heaps of silver and gold, is seized with a
prodigious lethargy." His heir, with unconcealed joy, is
scouring about the house in search of keys and cofEers.
Then the quick-witted and faithful physician rouses his pa-
tient in the following way: He orders a table to be brought
in and the bags of money to be poured out upon it and sev-
eral persons to begin counting it. At the ring of the coin,
the sick man jumps upon his feet, whereupon the doctor ad-
dresses him thus : " Do you not know that your ravenous
heir will carry off your treasures unless you watch them?"
" Not while I am still alive ? " " Why, certainly ; rouse your-
self, man ! " " But what must I do ? " " Why, you must
have food and restoratives; you are almost bloodless, already.
Come no foolishness, take this bowl of gruel." " How
much did it cost ? " " Oh, a trifle." " But tell me exactly."
" Two pence." " Alas ! what does it matter whether I die of
disease or by robbery and extravagance ? " The disinter-
ested character of the doctor is well brought out in this
scene.

"'0 Jupiter!" thou who causest men to suffer and re-
movest their afflictions (cries the mother of a boy confined

12 Epist. I, 13, 5.

'■'"Roman Life in the Days of Cicero," by Prof. Church, 1881.
I'Sat. II, 3, 142. See Celsus Lib. Ill, 20, who says it is a dangerous
acute disease with paroxysms and fever, probably congestive chill.
15 Sat. II, 3, 88.

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

235

to bed for five months), if this quartan chill shall at thy
command leave my child, on thy fast day he shall be placed
naked in the Tiber." Should chance or the doctor relieve
tlie patient from his imminent danjier, the superstitious
mother will destroy her child by placing him on the cold
bank and bringing back the fever."

"' A new disorder expelled the old in a miraculous manner,
as it is accustomed to do, when the pain of the afflicted side
or head is turned upon the stomach; or as it is with a man
in a lethargy, when he turns boxer and attacks his physi-
cian.""^

To Maecenas, he writes : " " In this case " (i. e., where the
judgment is disordered), " you think me mad, only as the
generality of men are mad, and you do not laugh or believe
that I stand in need of a doctor, or of a guardian assigned by
the praetor."

To his friend C'elsus, he writes," more of his mental than
his physical troubles, "Diseased as I am, I am willing to
hear nothing which may relieve me, I am displeased with
my faithful physicians and am angry with my friends for
their unceasing efforts to rouse me from my fatal lethargy."

To Augustus, he writes : " " He that knows naught of
ships will be afraid to work one; none but those who have
been taught will dare administer to the sick even a dose of
southernwood ; mechanics handle tools, doctors stick to their
medicines, whilst we poets write verses whether we are
learned or unlearned."

To his friend, Julius Florus," he writes : '' If no abund-
nnce of water should relieve your thirst, you would tell it
to your physicians."

Horace mentions by name two physicians — Antonius Musa
and Craterus; perhaps a third person of distinguished medi-
cal attainments is named— I will discuss this question later.

.Vntonius Musa, a highly educated Greek freedman of
Augustus, was led to the study of medicine by a desire to
relieve his father, who suffered from great infirmities.
lie acquired very great honor and distinction by curing
his master of a severe attack of illness, which had
resisted all previous attempts at cure, and seemed likely to
prove fatal. (Jf the nature of this attack we arc not posi-
tively informed (some say gout) but it had been treated by
lii.it fomentations and sweating without relief. The case
seeming so desperate, a change of physicians was determined
upon and Jlusa was placed in charge. Bold and decisive ac-
tion seemed to l)e demanded and consequently the entire
previous method of treatment was reversed. Cold douches
v.cre freely applied and the august patient was drenched
with draughts of cold water. With these measures, whether
pnsl or propter hoc. he recovered and, although his health was
always delicate, he lived for 36 years after this critical ill-
ness. By this happy termination, the physician reaped
a rich reward. He was invested with citizenship and the
order of knighthood; a large sum of money was bestowed

i»« Sat. II, a, UT.
'SEpist. II, 1, 114.

inEpist. I, 1, 101.
lEpist. II, 2, 146.

Epist. I, S, 7.

upon him by Augustus and the Senate, and his statue in
brass, erected by public subscription, was placed by the
side of that of the God of Medicine, in the temple of
Aesculapius, which stood on an island in the Tiber. Nor
did he alone profit by his good fortune; it was shared
in large measure Ijy all the disciples of Hippocrates in
Rome, who now, for the first time, acquired citizenship,
and were relieved from all civil burdens. The Methodists —
the sect to wliich JIusa belonged — naturally profited most
by this elevation and became the predominant body in the
profession of the Roman capital. Cold bathing became of
course the fashionable fad, and winter offered no bar to its
use. In Epist. I, 1.5, Horace asks his friend Caius Neumo-
nius Vala about Yelia and Salernuni, two winter resorts; he
wants to know about their climate and air, their people,
roads, water, corn, fish, hares and boars. He had long been
in the habit of spending his winters at Baiae, where there
were warm sulphur springs famous in the treatment of ner-
vous disorders. But now that delightful resort is deserted,
its myrtle groves are silent and the villagers are murmuring
against the fashionable physician, who has deprived them
of their patronage and Horace is preparing to follow Musa's
directions and the crowd, and seek waters less relaxing and
of lower temperature. Musa was also the physician of
]\Iaecenas, and it is related tliat he employed the distant
murmuring of falling water for that statesman's terrible in-
somnia, obtaining, however, only temporary relief by this
measure for his patient, everything failing at last. He was
the intimate friend of Virgil, who praises his taste and skill
in an epigram, affirming that he was loaded with all the
favors of Apollo and the muses."" He is spoken of by Dion
Cassius, Caius Plinius Secundus and Galen. The last-
named quotes him frequently. Strange to say he is not
mentioned by Celsus. He introduced into practice the let-
tuce, chicory and endive and was the author of several phar-
maceutical works of which only a few fragments remain.
These were collected and published by Flor. Caldani, in
8vo, Bassano, 1800. Several medicinal compositions bear-
ing his name enjoyed celebrity for a long time. Musa had
a brother, Euphorbus, who was physician to .Tuba, King of
Mauritania, and who discovered and gave his name to the
plant Euphorbia.

In the imaginary conversation in which Damasippus main-
tains that most men are mad," the philosoplier Stertinius is
represented as saying: ''Suppose that Craterus" [the
physician] "should pronounce a patient free from disease
of the stomach " [noii cardiacus]'^ " is he therefore well and
shall he get up ? No, the doctor will forbid that because he
is suffering from an acute pleurisy or nephritis." And so
he argues, if a man is not insane in one direction, he is in
another. Craterus was likewise a Greek, and stood in high

■0 Virgil's Catalecta. -' Sat. II, ",.

"Heclier believes that the disease knowu as '^ Cardiacus" has disap-
peared and that it was peculiar to aiiliiiuity. Vcdrenes, Traitc de Celse,
Paris, 1876.

236

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

repute in Eorae; Sir Theodore Martin calls him the " Aber-
nethy of his day." He is mentioned a number of times by
Galen. Cicero writes to his friend Pomponiiis Atticus (B. C.
45) upon hearing of the illness of the latter's daughter:
" De Attica doleo '" — " credo autem Cratero."' Persius writes:''

"Venienti occurrite morbo,
Et quid opus Cratero maguos promittere montes,"

" meet the disease at its first stage and what occasion is there
to promise Craterus gold mines for a cure ? " Porphyry "
gives an account of the cure by him of a slave attacked with
a horrible disease, in which the flesh separated from the
bones. He also invented an antidote against the sting or
bite of venomous animals.

The name Celsus occurs twice in the writings of Horace —
Epist. I, 3 and Epist. I, 8. The first is addressed to Julius
Florus, who has gone to Asia Minor, 20 B. C, A. U. C. 733.
as companion of Claudius Tiberius Nero, Augustus" stepson
and successor in the imperial chair. Tiberius, who was him-
self but 22, was accompanied on this occasion (his Armeniau
expedition), by a number of young Eonians of taste and
genius — the " studiosa cohors" as Horace calls them —
among whom were philosophers, historians, orators, poets
and doubtless a physician or two. " What works is the
studious train pursuing ? "' asks the poet. Among others he
refers to one named Celsus, and in the following words:
" What is my dear Celsus about ? already advised he shall be
advised again and again,'" to collect treasures of his own,
and to let alone writings, which arc stored in [the library
of] the Palatine Apollo, lest, if it should chance that the
flock of birds should hereafter come to claim their feathers,
he, like the jackdaw, should be stripped of his stolen colors
and become the subject of ridicule." The reference is to
the well-known fable of Aesop. The library here referred to
was one which had been founded by the Emperor Augustus
in his palace on the Palatine Hill, next to the temple of the
god. It was designed for the use and encouragement of
literary men and is several times referred to by Horace.''
Here was collected the literature of the world, all the writ-
ings which were judged worthy of " cedar and immortality."
Hither gathered scholars of every kind to consult the liter-
ary treasures, and it is said that the physicians here gave in-
struction to their pupils. The question naturally arises —
may not the great medical writer Celsus have here prepared
those compilations of philosophy and medicine, of which the
eight books " De Medicina," written in most elegant Latin
alone survive to this day? May not the young Celsus men-
tioned by Horace have been the great author himself?

Epist. I, 8 was addressed to Celsvs AUiinovanvs, whom
Horace describes as the attendant and secretary of Tiberius
Claudius Nero, the general in the Armenian campaign al-

«' Sat. Ill, 64. •■• Dc Absdm'Htiii ,ih AnxDndihns, I, IT, (il.

'-' Of the use of the verb moneo here I lind this in Gulielmus
Brauubardus, " Quinti Horatii Flacci, Opera. Omnia" Leipzig, 18:i.t :
'^ monem IIS jure qiiorlam nostra et mictoritate ; hortnmnr fere argumenlis,
Cruq."

■»Sat. I, i, 32 ; Sat. II, 10, 38; Epist. II, 1, 2115; Epist. II, 3, 94.

ready referred to. The use of medical terms in this epistle
is somewhat significant : " I will hear nothing, learn noth-
ing that may alleviate my sickness; I am displeased with my
faithful physicians, I am angry with my friends who are
striving earnestly to rouse me from my fatal lethargy."
The whole tenor of these letters shows that the greatest
intimacy must have existed between the writer and young
Celsus, and that the former entertained for the latter an
interest which was both fatherly and disinterested, for the
language, as has been remarked by Orelli and others, was
not intended in any offensive sense.

Now we know almost nothing about the medical writer
Celsus. The date and place of his birlh, residence and
death, are alike unknown. Even his name is in doubt, some
nuiintaining that the first initial " A," stood for Aulus, oth-
ers that it meant Aurelius. That he was a member of the
Cornelian family, to which so many illustrious men belonged,
indicates a patrician rank. It is uncertain whether he was
a practicing physician, with the probabilities much in favor
of the negative; yet his minute and accurate descriptions of
diseases, instruments and operations, his profound and inde-
pendent judgment and his frequent references to his per-
sonal experience, show a practical knowledge of the subject
which could only have come from prolonged observation and
actual participation.

What we do know of him is that he compiled a great en-
cyclopaedic work on various branches of learning of which
his eight books on medicine alone survive to this day. The
extent of this work, and the versatility of its author, are
shown by its embracing elaborate treatises on rhetoric,
philosophy, military science, agriculture (including a section
on veterinary science) and medicine. According to Gurlt,''
this compilation occupied some fifty or more years of the
authors life, the part on rhetoric having been written in the
last decennium before Christ and that on medicine at the
beginning of the fifth decennium after Christ under the
Emperor Claudius. The treatise on medicine was the
first medical work written in the Latin language and the
most important one of antiquity after Hippocrates. To it
we owe almost all that we know of the previous 400 years,
and of the great Alexandrian School of anatomists and sur-
geons. Our high estimate of it is not invalidated by the
fact that it was written for laymen, or by the neglect which
it met at the hands of Celsus' contemjioraries and success-
ors for many centuries, in fact until the revival of learning
in the 15th century. Its purity of style and literary excel-
lence render it a worthy cunipanion of the great non-nu^dical
classics of the Augustan age and have caused Celsus to be
termed the " Cicero Medicorvm.'^ That it was not appre-
ciated by the profession of Rome is probal^ly to be attributed
to two circumstances: 1, That it was addressed to laymen;
2, that the profession of Eome was made up almost entirely
of Greek physicians.

^'' GescMchte iler Chirnri/ie, "Vol. 1. See also Bahr, Gcschichtc dcr Rom.
LUerntur.

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

237

Is it possible to identify the Celsus of Horace with the
Celsus of medicine? It would have been nothing unusual,
if the young courtier, wlio had been honored by Tiberius
with the appointment of secretary, were well acquainted
with medical science, for it constituted, no less than phil-
osophy, a part of the education of all high-born Romans,
who often found in the " ampla valetudinaria," "' upon their
large country estates, abundant opportunities for the prac-
tical exercise of such knowledge. Again, to write such a
work as that of A. Cornelius Celsus, required access to a very
large collection of books, such as he would have found no
where in Italy except in Rome. He must therefore have
repaired to Rome, if not already a resident of the metropolis,
in order to carry on his researches, and if this be granted,
where would he have found such opportunities for work as
in the great collection of Augustus — the public library on
the Palatine Hill? Here then, we find two men of the name
of Celsus, simultaneously engaged in transcribing and com-
jiijing, not once but habitually and evidently for publication.
What is the inevitable inference? That they are one and the
same person.

The name, Alhinovnnus, seems at first sight to offer an
insurmountable obstacle to this theory. Let us consider,
liriefly, the nomenclature of Roman proper names. Every
free-born Roman of the higher class had three names. I. an
individual name or pra^iomen, as Auhis, Caius, Marcus,
Publius, (^uintus, etc. The number of these was limited.
They were considered titles of honor and as sucli were highly
prized, as Horace says: '' (/auilenf prcrnomine inoJles auricu-
lae." "' II. The gens name or nomen, as Claudius, Corne-
lius, Julius, Tullius, Virgilius. III. The individual family
name or cognomen, as Crispus, ilaro, Xaso, Plautus, Seneca.
The cognomen was sometimes assumed, " npliruni coyiio-
inen "; often it was conferred by the public:

" fieiiuentia Mercuriale
Impostiere milii cciiiiionieu com])itii," ■"

" the crowded streets gaye me the surname IMercurial." 1
imagine that such cognomina as canis,''" pinguis,'' Asina ""
and Asellus,"''' were rather in the nature of nicknames; they
would hardly have been adopted voluntarily by their hold-
ers. An additional cognomen was often added to a name to
indicate some circumstance of life, or character. In later
times this was called "agnomen." Such were Africanus,
Asiaticus, Numantinus, Capitolinus, Torquatus, (iernuinicus,
.Justus, Felix, Declamator. Thus are Publius Cornelius
.Scipio Africanus, Lucius Cornelius Scipio Asiaticus, Publius
Aemilianus Scipio Numantinus, Lucius Annanis Seneca
Declamator, Lucius Cal})urniu9 Piso Frugi, Decius .Junius
Brutus Scaeva and Albinus, Quintus Fabius Maximus Ctincta-
tor, Spurius Postumius Albinus Magnus and Regillensis, and
many others. Sometimes in the case of very distinguished
men there was more than one of these additional cognomina
or titles, and it was no unusual tiling for names to undergo

'''Celsus, Praefatio. *'Sat. II, .5, 32.

^'Sat. II, 3, 2.5. 13 Sat. II, 2, 56.

33» Epist. I, 13, 8. 33b Sic. & Liv.

3" Epi&t. II, 2, 10.
33 Sat. I, 3, 58.

change in course of time, old titles being dropped and new
ones assumed. Among friends, the mode of address was
usually by the gens nomen or the cognomen, the prsenomen
being reserved for formal or polite address, something like
Mr., Rev., Dr., Sir. In eight of the epistles of Horace,
omitting doubtful ones, his correspondents are addressed by
their cognomina; in six the gens name is used and in one
both; not once is the prfenomen used. The same rule pre-
vails throughout the entire work, the pra=nomen never being
employed. The poet refers to himself most often as Hora-
tius, once only as Flaccus and once as Quintus. Of Latin
authors who mention him, according to Horace Delphini,
eight speak of him as Horatius and five as Flaccus. From
all this, we may conclude that in '•' Celsus. Albinavauus" the
poet has omitted part of the name of his friend, quite cer-
tainly the pra:>nomcn and most probably the gens name also,
especially as we never find " Celsus "' used in this sense.
" Celsus," then being the cognomen or third name, what shall
we say of " Albinovanus."' Its position here, as well as in
the names JIarcus Tullius Albinovanus, Caius Pedo Albino-
vanus and Publius Tullius Allunovanus also mentioned in
the literature, show that it was a cognomen and not a family
or gens name, one therefore least important and most liable
to change. It may have been an accidental name, by which
he was known to his intimate friends or in early life, but
dropped later when he achieved reputation and literary re-
nown, the other three containing all that a Roman patrician
required."

I have examined a great many editions, lives, transla-
tions, etc., of Horace with reference to this theory,, and
have found it mentioned but once ™ and then with disap-
proval. It seems to have been first brought forward and
championed by Bianconi, an Italian author, in 1779." I
have not been able to find Bianconi's work in the libraries
here and have therefore not been able to avail myself of
his arguments. Targa, the author of the best text of Cel-
sus," and S]irengel in his great history of Medicine,"* both
agree with him.

Finally, a possible explanation of " Albinovanus " is found
in a German translation of the Epistles of Horace by Carl
Passow, Leipzig, 183.3. He translates Celsus Albinovanus,
" C. of Albinova," thus implying that this term indicated the
place of his birth or residence. This would assimilate it
still closer to the accidental cognomina, to which I have re-
ferred. I have met with this explanation nowhere else, and
I have not been able to find any such place as Albinova in
any of the geographical dictionaries, but it appears both
plausible and reasonable. The termination " anus " would

3^0relli regards "Albinovanus" as an " asnomeu ;" 3d cd. (Baiterus),
1852.

3'Orellius, i>p. cil.

3« Bianconi, Leltere sopra A. Cornel. Celsn, Knm, 177'.', S°, deutsch von
S. Ch. Krause, Leipz., 1781.

31 Targa, Leonard, 1st ed., Padua, 1769; 2d, 1810; 3d, 1815.

3* Sprengel (French trans., Paris, 1815, 9 vols.) savs "infinitely
probable." Targa devoted 70 years to the study of Celsus; all authors
since his day have adopted his text.

238

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

correspond with Romaniis, Trojanus, Albanus, etc., and the
name Albinovanus certainly suggests place, " albi " or
" albia nova." There were several towns of the name albi
or albia, and there was an Alba Longa, an Albaraarla, an
Albamala, an Albamana, and many similar combinations.
The termination " anns " indicates a double word since the
adjective termination of polysyllables was not " anus " but
" ensis."

It is pleasant, thus, to contemplate Horace as the friend ot
our Roman Hippocrates, and I feel sure that the works of the
genial poet will afford us increased delight from the con-
templation of this tie between our profession and him.

The following diseases are mentioned in Horace: dropsy,
dims hydrops: consumption, macies; malaria, quotidiana,
quartana frigida; fever, febris; pleurisy, dolor laierum., dolor
miseri lateris, morbus lateris acutus; polypus tmsi; headache,
dolor capitis; dyspepsia, dolor cordis; lethargy, lethargus.
vcternus; insanity, iracunda Diana, furor, insania, rabies:
nicer, ulcus, ulcera incurata; hydrophobia, rabies canis,
rabiosa canis; diabetes [if the lines

"Si tibi nulla sitim fiuiret copia lymphiv,
Narr.ires medicis;"

justify this diagnosis] ; wound, vulnus; itch, scabies; jaun-
dice, morbus regius; cold, frigus; conjunctivitis, lippitudo;
strabismus, strabo; club-foot, male pravce tales, crura dis-
torla; wart, verruca; protuberance, tuber; a horny growth
on the forehead, frons exsecto cornu; fracture of the leg, crws
fractum; Campanian disease, morbtis Gampanus [a skin
eruption accompanied by pimples or warts]; mole, ncevus;
gout, nodosa (knotty) chiragra, tarda (crippling) podagra:
cough, tussis; wax in the ear, atiricula dolentes collecta sorde;
plague, pestis; canities, and bites of dogs and serpents.

The allusion to dropsy is strikingly graphic: As the love
of money increases with its gratification, so " the direful
dropsy increases by self-indulgence, nor does it extinguish
its thirst, unless the cause of the disease has departed from
the veins, and the watery languor from the pallid body." '''
There is an allusion to this affection also in Epist. I, 2, 34:
" Si notes sanus, curre^ hydropicus," " although you are un-
willing to move when well, you will run fast enough " [to
the doctor], "when you get the dropsy." The origin of
consumption and fevers, as a retribution for the theft of
fire from heaven by Prometheus, is strikingly put —

" macies, et nova febrium
Terris incubuit cohors," ■•»

as if they were swarms of noxious winged creatures. The
polypus of the nose," resembled more ozsena, from the fetid
odor which accompanied it, than what we know as polypus.
The word scabies occurs three times. " Occupet extremum
scabies,"" "the devil take the hindmost!" The jaundice
is called " morbus regius," not because like scrofula in later
times, it was curable by the king's touch, but because, in its
treatment, it required care and delicacies which are supposed

" Od. II, 3, 13. 40 Od. I, 3, 30. 4' Epod. XII, 5.
" De Arte Poet.

to be attainable only by royal personages." Colligere frigus "
is " to catch cold "; tenlalus frigore " is '' seized with a cold."
" llic oculis ego nigra meis coUyria lippus illinere,"*° "here I
anointed my inflamed eyes with black ointment." What
this black ointment was is not stated in any of the com-
mentaries; Celsus gives the formul.T for several, among
which this may possibly be. Again we have " lippus
inungi,"" " Crispinus lippus,"'^ and "oculis lipptis in-
unclis." " The crippling effects of gout are portrayed at
Sat. II, 7, 14 : " That buffoon Yolanerius, when the deserved
gout had crippled his fingers, maintained a fellow, hired by
the day, to take up the dice and put them into a box for
him." The removal of the horny growth from the fore-
head of ]\Iessius, spoken of in the description of the journey
to Brundusium,°" was doubtless effected by some surgeon;
an ugly scar attested the operation. The Csesarean operation
is clearly referred to in the De Arte Poet., 339: "Nor take
out of a witch's belly" [o7t'o], "a living child, that she
had dined upon." In Sat. II, 3, we have a discussion of in-
sanity, with a description of various types. It enumerates
many well-known forms but omits others. There is no
mention, e. g., of general paralysis of the insane (referred to
by Pliny), nor of alcoholic, puerperal or epileptic insanity.
Although but a desultory description, it is worth a closer
study.

In Horace's physiology, the liver secreted bile as now, but
figuratively it was also the scat of anger and lust.

*' nu'uni
Ferveus difflcili bile tumet jc'cur,'"»'

" My inflamed liver swells with bile difficult to be repressed."

" libido
Saeviet circa jecur ulcenisum," ^-

" And hot lust shall rage about your ulcerous liver." " Noii
ancilla tuum jecur ulceret ulla," ''^ " let no young slave in-
flame your liver." " Meum jecur urere bilis," " " anger galled
my liver " [because his dear friend Fuscus Aristius would
not take the hint, when he was tormented by the bore on the
Via Sacra].

" Exucta uti medulla et aridiim jecur
Amoris esset poculum," *■'

" that they " [the witches] " might have a lovo-filfcr from
the parched marrow and dried liver" [of fhe boy]. At
Od. IV, 1, 12, the poet advises Venus to seek Paulus Maxi-
mus, "if she desires to inflame a suitable liver:" "si
torrerc jecur quairis idoneum." In Od, III, 4, 77,

"nee Tityi jecur
Relinquit ales,"

" the vulture feeds continually on the liver of Tifyus "" [the
giant, who had attempted violence upon Latona]. And
finally, we find this mention of the bile in Sat. II, 2, 75 :

" Dulcia se in bilem vertent, stomachoque tumultura
Lenta feret pituita,"

"See Celsus, lib, III, 24.
4J Epist. I, 2, 13.
"Sat. I, 1, SO.
" Sat. I, 5, 30.

*■> Epist. I, 1, 39.
«Sat. I, 1, 120.
« Sat. I, 3, 2.5.
50 Sat. I, 5, 58.

5'Od. I, 13, 3.

52 Od. I, 3.5, 13.

53 Epist. I, 18, 7
5J Sat. I, 9, 66.
"Epod. V, 37.

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

239

which Martin translates —

*' what tastuil so sweet
Will be tiirueil into bile, aud ferment, not digest, in
Your stMnaeh, exciting a tumult intestiue."

'i ho sjilrt'ii is uoi once mentioned, and with Horace it was
" f o vent the bile," not " the spleen."

Cor is used for heart or stomach, pro'cordia for heart,
chest or intestines. Ilia is also used in the last-named sig-
nification. " Vitio tumidum cor,'"" "heart swollen with
vice "; " tetigisse cor querela," "' " to move the heart with
complaint"; " corde tremit,'"" "trembles in her heart";
" in cor trajccto clolore," °° " the pain being transferred to the
stomach." " Ilia rliombi," °° " the entrails of a turbot "; " C*
dura mcssorum ilia,'''" said of those who eat garlic; ducere
ilia," "' " to become broken-winded." " Humana exta " " is
"human viscei'a." "Tenia spiritu prcecordia," °' "my chest
strained with gasping"; " condita cum verax aperit praicordia
Liher," " " when truth-telling Bacchus opens the secrets of
his heart ";

" leui pntcordia mulso
Prolueris melius," se

" you will with more propriety wash your stomach with soft
mead"; "quid hoc veneni saevit in prcecordiis," " "what
]ioison is this that rages in my entrails?" [said of the gar-
lic |; " f< iuquietis assidens prcecordiis," " "and brooding
ujion your restless breasts"; " inceduit prcecordiis,'""' "boils
ill my breast."

The lungs are not mentioned once, and the medulla [be-
sides the quotation already given] only in this passage:
" certius accipiei damnum propiusve medullis," '" "' and nearer
to his marrow."

Disease of the nerves is referred to once only," but
" nervi " is to be understood rather as signifying tendons
and muscles than nerves. " Cerebrum " is used for brain or
head: " trunciis illapsus cerehro,"^' " felix cerebri,"'' " puti-
dius niullo cerebrum." '* " Cerebrosus " '° indicates " a chol-
eric fellow."

" Foul lust " inflames the veins " as well as the liver.
Wine flows into the veins." The cause of disease resides in
the veins.™ "To commit to the -empty veins."" There is
no mention of the arteries (Celsus uses " vens " as a general
term for both).

" Venter " is used almost always for the organ of digestion,
luit in Epod. XVIII, 50, it signifies the womb, and in Epist.
1, 15, 36 the abdomen, " were venlrcm," " to brand the ab-
domen." " SiomacJius " also generally implies the organ of
digestion, but once it is used to signify " anger," once
" breast " and once " disposition."

"Sat. II, 3, :MS.
« De Arte Poet., 98.
"Od. I, 23, 8.
"Sat. 11, 3, as.
"» Sat. II, 8, 30.
«' Epist. Ill, 3, 4.
«* Epist. I, 1, 9.
"DeArte Poet., ISG.

" Epod. I, 18, a.5.
' " Sat. I, 4, 89.
«6 Sat. II, 4, 3C.
" Epod. Ill, .5.
ssEpod. V, 95.
69 Epod. II, 1.').
" Epist. I, 10, :>8.
"Epist. I, l.'j, 0.

"Od. II, 17, 27.
"Sat. I, 9, 11.
" Sat. II, 3, 7.').
"Sat. I, 5, 21.
'6 Sat. I, 2, 33.
" Epist. I, 1.5, 18.
"Od. II, 2, 14.
"Sat. II, 4, 25.

" Guttur frangere'"" is to break one's neck; " cervicem

frangere " " is used in the same sense.
The midwife is referred to once :

" et tuo
Cruore rubros obstetrix panuos lavit,
Utcunque fortis exsilis puerpera," »-'

" and the midwife washes the rags, red with your blood, as
often as you bring forth, springing up with unabated vigor."
This is said in derision of Canidia the witch. " Laudantur
simili prole puerperce," ''' " mothers are praised for the re-
semblance of their offspring," an allusion to the blessings
Augustus had conferred upon his country.

'* Diana, quae laborantes utero puellas,
Ter Tocata, audis, adimisque letlio,"*'

"' Diana, who when thrice called, hearest young women in
the throes of childbirth and snatchest them from death."

Constipation is referred to in the words, " dura viora-
bitur alvus." '"

Horace's materia medica is singularly limited. Of drugs
he mentions the following only: " malva," " mallows; " lapa-
thum,"" sorrell; " elleborum," " hellebore; " abrotanum," '"
southernwood; " cicuta,"" hemlock; " papaver,"" poppy.

The mallow was used for food and also as a remedy for
various disorders, as indigestion, irritation of the kidney and
bladder, etc. : " gravi malvw sahibres corpori." '' Celsus rec-
ommends it frequently as an emollient and laxative.

There were two varieties — the cultivated, saliva, and the
wild, silrestris. The mallow (" althwa '") is still employed in
medicine as a demulcent and emollient. The root of the
plant which grows in salt marshes and other moist places is
alone officinal. It is obtained from Europe.

The sorrel, known among tlie Greeks as " lapatlion " and
among the Eomans as " rumex," grows also in swamps. It
was described by Pliny and Dioscorides, according to the
latter being stomachic, laxative and diuretic. Celsus recom-
mends it as a laxative. It is still embraced in our materia
medica, having an agreeable sour taste (due to acid oxalate
of potassium) and valuable antiscorbutic properties.

Hellebore was in great repute in the treatment of insanity.
According to Pliny,'' it will cure paralysis of the insane
{'' jjaralydcus iitsaniens"), expelling bile, fajces and mucus
and with these " the melancholy humor." The same author
states that the illustrious tribune, Drusus, was cured by it of
epilepsy. Celsus does not mention it. The plant was found
in great abundance on the island of Anticyra, in the Aegean
Sea, and thither wealthy patients with mental disorders were
sent to undergo courses of treatment with it. Hellebore
(known as " Ilelleborus Orientalis") is still found growing
in the Island of Anticyra. It is distinct from the black
hellebore, which is also found in Greece, though probably
possessing similar properties.

so Epod. Ill, 2. 82 Epod. XVII, 50. 84 od. Ill, 22, 2.

8' Od. II, 13, 6. 82 Od. IV, 5, 23. ss gat. II, 4, 27.

86 Od. I, 31, 16; Epod. TI, .58. *« Sat. II, 3, S3; Epist. II, 2, 137.

''Sat. II, 4, 29; Epod. II, 57. «=' Epist. II, 1, 114.

MEpod. Ill, 3; Sat. II, 1, 56; Epist. II, 2, .53. '^ Epod. II, 57.

»' De Arte Poet., 375. »3 Lib. XXV, cb. 15.

240

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 135.

The ahrotannm (southernwood) was an evergreen plant, of
very bitter taste; both leaves and seed were employed and
were considered by Pliny and others to be highly useful in
diseases of the nerves, coughs, lumbago, urinary diiliculties,
poisoning, etc. Celsus recommends it as a diuretic in dropsy.
In the last edition of the U. S. D., the leaves of Artemisia
Abrotanum, L., or southernwood, are said to have a fragrant
odor and a warm, bitter, nauseous taste and to have been
formerly employed as a tonic, deobstruent and anthelmintic.
It is allied to the Artemisia Ahsintliiuin. from wliich the in-
toxicant absinth is derived.

The cicitta (hemlock) was a painless poison, producing nar-
cotism with coldness of the body. Among the Athenians,
those condemned to death were compelled to drink its juice ;
thus perished Socrates and Phocion. It is mentioned twice
by Celsus. The effects of the modern conium which is sup-
posed to be identical with it, are anodyne, soporific and anti-
spasmodic. " After toxic doses, the muscular prostration is
extreme, the eyelids drop from weakness, the voice is sup-
pressed, the pupils dilated, the light almost lost; conscious-
ness is usually preserved to the last and life is filially ex-
tinguished without a struggle. . . . Probably the most fre-
quent use of it is by alienists for the production of calm in
maniacal excitement." (U. S. D.)

" Sed mala toilet anum vitiato melle cicuta," " " the deadly
hemlock in the poisoned honey will take off the old dame ";
riciitis aliuin norentius,"'^ "garlic more baneful than hem-
lock."

The poppy is mentioned in " De Arte Poet.," 375: " Sardo
cum melle pa paver,'' " the poppy mixed with Sardinian
honey," rendering it very bitter and therefore cheap. The
papaver, both "album" and " /nV/ri/m "' is often spoken of
by Celsus in connection with its hypnotic effects.

" F omenta," both hot and cold are mentioned: "Fomenta
rulnus nil malum levantia,"" " applications that give no ease
to the desperate wound"; "fomenta parare"f '' frigida
curarum fomenta," *" " the cold fomentations of care." In
Epist. I, 2, 52, fomentations are said to be " as useful to
the gout as paintings to the blind or music to the deaf,"
from which we may infer that they were not in much esteem
in that disease.

" Sat. II, 1, 56.
" Epod. Ill, 3.

96Epod. XI, n
9' Sat. I, 1, 82.

98 Epist. I, 3, 26.

Baths, cold, hot and sulphur, are frequently referred to.
It is well known how large a part they took in Iloman life,
both in health and disease. It is singular that there is no
mention of blood letting or cups which were then in fre-
quent use. The leech (first recommended by Themison,
Horace's contemporary) is mentioned once and is the very
last word in the book:

" Non missura cutem, nisi plena cruoris, liinido," "a leech
that will not quit the skin till saturated with blood"; this
is said of the " recitator acerlus," " the merciless reciter of
verses," " the mad poet." It is not mentioned by Celsus.

There are several allusions to the unhealthfulness of the
autumn season at Rome; " the sickly hours of September ";""
" the sickly season of autumn " :'"" " the undertaker with his
black attendants, active in autumn," '"' or as Martin inter-
piets it :

" this deadly time of .year,
Wlien autumn's clammy lieat and deadly fruits,
Deck undertakers out and inky mutes ;
When youni; mammas, and fathers to a man,
With terrors for tlieir sons and lieirs are wau.
When stifling anteroom or court distills
Fevers wholesale, and breaks the seal of wills."

Again

" the southern breeze
That through the autumn hours wafts pestilence and bale." '"'-

From line 302, De Arte Poet., there would seem to have
been a custom among certain of the Romans of submitting
to an annual vernal purgation:

" O ego Uevus
Qui purgor bilem sub verni temporis horam."

In Epod. XVIII, 35, Horace calls the witch Canidia, a
shop or laboratory of poisons, " venenis officina Colchicis,"
just as we now say a man is " an encyclopa?dia of knowledge."

In Sat. II, 5, 7, Ulysses finds neither his " apotheca," i. e.,
" cellar " or '' storehouse," nor his flock, untouched by the
suitors of Penelope.

Among those who grieve over the death of the singer,
Tigellius, are the " pharniacopohe," "" a term which Smart
says was a general appellation for all dealing in spices, es-
sences and perfumes. It is probable that they also dis-
pensed drugs to the poorer classes.

99 Epist. I, 16, 16.
'""Sat. II, 6, 19.

"" Epist. I, 7, 6.

i«» Martin, Od. II, 14, 1.5.

103 Sat. I, 2, 1.

A HISTORICAL NOTE UPON DIPTERA AS CARRIERS OF DISEASES-PARE-DECLAT.

By Howard A. Kelly, M. D.

(Head before the Johns ffopkins Hospital Historical Club, Monday, March 11, 1901.)

It is with no little sense of satisfaction that the surgeon
contemplates the recent enormous advance so unexpectedly
made in the direction of hygiene and preventive medicine,
an advance of even greater significance I am inclined to
think than the discovery of Jenner, and one which is fairlv

comparable to the introduction of the antiseptic principle
into surgery.

It is a curious fact that our greatest acquisitions some-
times steal upon us so silently and so unheralded that before
we know that any change has occurred a new principle has

August, lOdl. |

JOHNS HOPKINS HOSPITAL BULLETIN.

241

been quietly evolved, and we find ourselves in possession of
facts destined within a few years to save millions of lives
and a vast sum of morbidity, where life is not lost. Such
too is the ease with this recent greatest medical discovery of
the significance of the diptera and other insects as inter-
mediary hosts and conveyers of contagion.

The interest in the subject which has been aroused in this
country can be inferred from these admirable monographs
and pa])ers, some of which I here present to the Society:

Geo. H. ¥. ISTuttall, On the Eole of Insects, Archnids and
Myriapods as Carriers in the Spread of Bacterial and Para-
sitic Diseases of Man and Animals. The .lnhns Hopkins
Hospital Eeports, Baltimore, 1S99.

Victor C. Vaughan, Conclusions reached after a Study of
Typhoid Fever among the American Soldiers in 1898. Jour.
Am. Med. Assoc, June 9, 1900.

Geo. M. Kober, Eeport on the Prevalence of Typhoid
Fever in the District of Columbia, published in the Health
Officer's Keport for 1895. I have to thank Dr. Koher for
this manuscript copy of his investigations.

Walter Reed, The Etiology of Yellow Fever. Jour. Am.
Med. Assoc., Feb. 16, 1901.

Charles Finlay, The ^Mosquito Theory of the Transmission
of Yellow Fever, with Its New Developments. ^Medical Re-
cord, Jan. 19, 1901.

L. 0. Howard in the Proceedings of the Washington
Academy of Sciences presents most valuable data in " A
Contribution to the Study of the Insect Fauna of Human
E.xcrement,"' Washington, 1900; Dr. Howard collected 77
species of diptera, of which 36 species were found to breed
in human excrement. The commoner and more important
forms can easily be identified by means of the admirable fig-
ures scattered through the text.

Previous to this article no systematic attempts had been
made to identify the species, all of which were simply spoken
of generically as " flies."

L. 0. Howard, Ph. D., remarks that in general there may
be said to be three predominant types of tlies, the medium-
sized gray, of the type of the common house fiy (musca do-
mestica), the metallic green and blue bottle flies, and the
small dark brown or black flies of the Homalomyia tyiu>.

Several species belonging to the different families so
closely resemble the house fly that they cannot be distin-
guished without a close study of structural characters.

I know myself by questioning friends during many past
summers that few laymen even recognize the difEerence be-
tween the common house fly and the gray horse fly of the
same size (stomoxys calcitrans) with his prominent biting
proboscis.

The importance of the recognition of specific differences
is manifest when we come to study the life history of flies
with a view to extermination.

An instructive article for the lay scientific world by Dr.
Howard will be found in the Popular Science ifonthly for
Jan., 1901.

My object in presenting this matter to the Society this

evening is, however, not to review a subject already very
large but simply to present two brief historical notes whii-h
I think have as yet escaped the attention of any writer. I
am glad that my little historical investigations in both in-
stances serve to illuminate the great genius of our French
confreres and add but another to the many instances in
which they have been shown to lead the M'orld in the field
of science.

The first clear statement as to any definite relationship
existing between flies and disease as that of cause and effect
is found in the works of Ambroise Pare in his " Apologie,
et Traite eontenant les Voyages Faits en Divers Lieux,"
where he describes how after the battle of St. (Juentin (1.557)
he was sent by the king to la Fere in Tartenois. Arriving at
la Fere, Pare was charged as he was about to return by M.
le Mareschal de Bourdillon to remain and dress the wounded
survivors of the battle, " which," as he tersely says, " I did "
(" ce que je fis ").

He found the wounds excessiveh' fetid and full of worms
with gangrene and corruption; and it was necessary to give
free play to the amputating knives in removing the decay
in cutting off arms and legs; there were also sundry trephin-
ings. To stop the gangrene and kill the worms he washed
the wounds with Egyptiacum dissolved in wine and lirnndy,
but in spite of all his cares a great number died.

Now there were at la Fere some gentlemen charged with
the business of finding the dead body of M. de Bois-Dauphin
the elder, who had been killed in the battle, and they begged
Pare to assist them in their search, but it was impossiiile to
recognize him as the bodies were all so far gone in corrup-
tion and the faces so disfigured. " For more than half a
league around, the earth was covered with dead bodies, and
we could hardly stop there on account of the terrible cada-
verous odor which they exhaled, men as well as horses: we
were too the cause of a rising up from the bodies of a great
number of large flies gendered by the moisture of the bodies
and the heat of the sim; they had green and blue bellies
and when they were in the air Ihey cast a shadow on the sun.
It was wonih'rful to hear thciu buzzing and wherever they
settled they made I he air ])estilent and there they caused
the pest."

Verbatim : " Nous f usnies cause de f aire eslever de ces corps
une si grande cjuantite de grosses mousches, qui s'estoient
procrees de rhumidite des corps morts et de la chaleur du
Soleil, ayans le cul verd et bleu, qu' estans en I'air faisoient
ombre au Soleil. On les oyoit bourdonner a grand merueille,
et croy qua la on ils s"assirent, e'estoit pour rendre Fair
pestilent, et y cause la peste."

The value and completeness of the observation of this
great surgeon is fully appreciated when we consider how
short a step it is necessary to take in order to make a prac-
tical application in the prevention of the infection thus dis-
tributed by flies, whether by inhumation or incineration of
the dead bodies or by the use of screens to protect the living.

What benefits might not have accrued to humanity during
the past two and a half centuries had some inquiring nund

242

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

gone to work to submit this magisterial dictum to a few
simple jJractical tests !

lu the year 1668, after a severe visitation of the plague a
distinguished natural philosopher, a Jesuit priest named
Athanasius Kircher (Scrutiuiuni physico-medicum Conta-
giosae Luis, quae Pestis dicitur etc. Komae 1658, p. 145), in
writing of the causes of the plague — " De mirandis contagii
sive foinitis pestiferi etfectibus, et quaenam res contagii
eapaces sint," says under the remarJvable caption " muscae
pestis Seniinatives," including bees as well as diptera under
the title " uiusca,"' " Last of all flies according to Mercuri-
alis, saturated with the juice of tlie dead or of the diseased
then visit neighboring houses and infect the food with their
filth. A hornet lit on the nose of a certain nobleman in tlic
late Neapolitan plague, who was looking out of the window,
and stung him and in two days he was dead."

My next claimant for honors is also a Frenchman, G.
Declat, a man of great ability born both too early and too
late, too late to be recognized as the discoverer of antisepsis,
for that honor belongs to his quondam friend and com-
petitor Lemaire, but too early for recognition of his merits
by the world at large, tor his work .still had to await another
generation to find suitable recognition and approval.

Declat writes, in his work entitled " Nouvelles Applica-
tions de I'Acide Phenique en Medicine et en Chirurgie aux
Afi'ections Occasionuees par les Microphytes — les Micro-
zoaires — les Virus, les Ferments," etc., Paris, Oct., 1865:

" De Facide Phenique dans les cas d'emploisonnemenls
transmis par les insectes.

Dans notre clLmat nous n'avons pas de mouches reellement
venimeuses, e'est-a-dire quune piqure de mouche seule ue
suffit pas pour amener des accident graves, quelle que soit
la partie du corps qu'elle pique. x\.iusi, la piqiire des abeil-
les, des quepes, des frelons ne pent entraiuer que la douleur
ou ^n peu d'enflure plus ou moins considerable, selon la
nature des tissus atteiuts par I'insecte. Mais si la mouche
n'occasionne pas d'accidents graves par sa piqure proprement
dite, elle pent cependant etre la cause indirecte de desordrcs
qui entrainent quelquefois la mort.

L'expHcation en est facile, et c'est cette explication qui
nous donuera la clef des moyens propres a nous en preserver;

Les mouches touchent a tons les corps et de preference
aux corps vegetaux ou animaux qui sont en decomposition.
Or, la decomposition n'est autre chose que la desorgauisa-
tion par les ferments, par ces etres microscopiques, dont le
but dans la nature est de detruire tout ce qui a vecu, tout ce
qui vit et tout ee qui vivra. La mouche transporte souvent,
au moyen de ses pattes, de ses ailes, de sa trompe ou de ses
mandibules une quantite plus ou moins grande de ces etres
destrueteurs. Si elle se pose sur un etre vivant, et que la
partie de son corps empreinte du virus contagieux touche la
peau de eet etre vivant a I'endroit d'une ecorchure, quelque
petite qu'elle soit, elle y depose ce ferment, et peu a peu il
penetre a travers Fecorehure ou Feraillure de la peau, se
mele au sang, et devient le point de depart de tons les acci-

dents auxquels donne lieu la penetration de ces etres dans le
sang, ou ils se multijjlient.

Si Fensemble de ces circoustances ne se presente pas plus
souvent, on doit s'en etonner, car les mouches recherchent
toujours les parties denudees de notre corps et se placent do
maniere a pouvoir pomper un liquide qui leur serve d'ali-
meut; or elles le puisent dans le fond des pores, dans les
parties fines de la peau, le pourtour des yeux, par exemple,
et surtout dans les ecorehures, dans les eraillures, les cou-
purcs, les boutons, etc. Si les accidents ne sont pas plus
frequents, c'est que la loi organique qui defend les viseeres
et maintieut la vie, comble rapidement les fissures de la peau
par la secretion d'une matiere coagulable a Fair. Et, des
lors, hi mouche, quoiq\ie se plagant sur ces parties, y depose
bieu un principe dangereu.x, mais par bonheur ce principe ne
pent penetrer que bien rarement.

Par une prevoyance providentielle, les mouches armees de
(elle sorte qu'elles peuvent attaquer la peau, sont moins
portees que les autres a se uourrir de matieres septiques; sans
cela, comme elles font elles-memes une porte d'entree, soit
avec un aiguillon, soit avee des mandibules, elles feraient
penetrer avec leur venin le germe des infucoires mille fois
plus dangereux que ce qu'elles peuvent deposer elles-memes.

Le danger reel vient done surtout du contact des mouches
qui ne piquent pas, et cela parce qu'on ignore ce danger qui
nous menace et qu'on ne le soupgonue qu'apres les premiers
symptomes de gonflement, de malaises ou des maux de coeur,
et quelquefois il est deja trop tard, comme cela arrive si
souvent dans la pustule maligne. Par quel moyen done se
preserver de ce danger qui est reel ?

Le premier et le meilleur serait de ne Jamais laisser a
Fair libre un corps en decomposition, d'enterrer toujours
assez profondement les cadavres des animaux, surtout lors-
qu'ils sont morts de maladies douteuses, de ne jamais les
Jeter dans les rivieres, dans les fleuves et encore moins dans
les eaux stagnates; le second est d'avoir toujours chez soi
et encore mieux sur soi, pendant Fete, un flacon d'acide phe-
nique. L'actiou do cet acide est precieuse et rapide dans ces
circonstances: comme preuve, Je citerai une observation que
j'ai recueillie tout recemment."

What could be clearer than these simple lines? All that
is wanting is the vigorous scientific experiment to prove the
absolute correctness of the observations for he says:

a. The fly visits bodies in process of decomposition.

h. Decomposition is nothing more or less than destruction
by ferments which are living microscopic structures.

c. The fly transports on its feet, its wings, its proboscis,
or its mandibles, some of these destructive agents.

d. This material is carried to and deposited upon the living
body, where, if there is any abrasion, or fissures or any solution
of continuity whatever, the contagious virus does its work by
entering the vascular system and multiplying indefinitely.

Wliat more could one ask? Perhaps the recognition of
the different species of microorganisms and a few modern
experiments to prove the thesis. But one must leave at
least a little ground for subsequent workers to cultivate!

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

243

THE FIFTIETH ANNIVERSARY OF THE INVENTION OF THE OPHTHALMOSCOPE.

By Harry Friedexwald, A. B., M. D.

(.Read before the Hintvi-ii-al I'lub of the JohnslHopkinx^IInspitnl, Mareh 11, IHOI.)

It is just 50 years since the ophthalmoscope was invented.
It seems proper to make reference to an event of such im-
portance before your Historical Society and I have thought
that it would interest you to spend a little time on a review
of the origin and development of the instrument. It is of
special interest to consider the gradual accumulation of facts
and observations, the building stones which were required
before even the genius of a Helmholtz could rear his struc-
ture. The most important of these was the observation of
tile luminous appearance of the pupil, which I dare say all
of you have often seen in animals and human beings. It
was easy for us to make the observation because the fact had
lieen pointed out. But most of us are very poor observers
and generations and generations of common people, of
learned men, of practitioners of medicine and of ophthal-
mologists came and went and yet the observations bearing
upon this fact stand out as a few isolated instances through-
out the centuries.

The ancients observed the luminosity of the eyes of cer-
tain animals for there is doubtful mention of it by Aristotle,
ami I'liiiy says " the eyes of nocturnal animals, such as cats,
are brilliant in the darkness." Simihir observations were
later on made in the dog, horse, sheep, weazel, hyena and the
birds of prey.

The first mention of the observation in the human eye
was made in 1796 by Ferniin who saw that the pupils of an
Ethiopian Albino were luminous. Other cases were pub-
lished, as rare and curious, during the first quarter of the
19th century and some went so far as to state that the light
radiating from such eyes illumined the objects on which it
fell and enabled the fortunate individual to read in the
dark. The bright yellow appearance of the pupils in cer-
tain forms of disease, first mentioned by Scarpa in 1816, was
classically described by Beer in 1817 under the title of
" Amaurotic Cat's Eye."'

We find no mention of luminosity in other than albinotic
or diseased eyes until 1837 when Behr observed it in a case
of total iriderimia and it was not until the forties before
the observation was made on normal eyes.

It is interesting to learn the theories that were offered
to explain these observations. First it was regarded as a
phenomenon of phosphorescence, by some as the light ab-
sorbed during the day and given off at night and later by
others as the result of an internal activity similar to that of
the fire-fly. It was described as varying with the seasons,
with the age of the individual and with his nervous state.
Electricity was also called upon to assist in explaining the
luminosity of the eye. It was the " naked electricity emit-
ted by the retina, for nowhere in the animal organism is the
brain substance exposed to the naked eye as clearly as in
the open interior of the eyeball " (Pallas, 1811).

But Prevost in 1818 pointed out the true cause — the re-
flection of the light which entered the eye, and Gruithuisen
about the same time came to a similar conclusion. In 1821
Eudolphi added the observation that success of the experi-
ment depended upon having the light thrown in, in a definite
direction and that the eyes of the decapitated head of a cat
were as easily made luminous as in the living.

Esser in 1836 showed tliat such eyes show even brighter
than the living because of the larger size of the pupil, and
Johannes Slueller reached a similar conclusion. In 1836
Hasenstein showed that he could make the pupil luminous
by compressing the eyeball in its anteroposterior diameter,
and in 1845 Brucckc gave the correct explanation of the red
color of the luminous pupil in that the light was reflected
by the choroidal blood-vessels.

In the following year a most important communication by
Cumming in ^fed. Chir. Trans, was made. He showed that
every healthy human eye can be made luminous. The per-
son is placed at a definite distance from a light, this dis-
tance varying with the intensity of the light and the ob-
server places himself close to the straight line between the
course of light and the eye examined. He showed that the
luminosity of the pupil varied with the intensity and the
distance of the light and that when the distance was de-
creased to a few inches it vanished because the light is cut
off by the head. He re])orted a number of cases, in one of
which only could he not ])ro(luce the luminous appearance.
In this case the juijiils were very small. It was Cumming
who first suggested and used this method for examination of
the posterior portion of the eyeball, making the endeavor
to draw conclusions concerning the retina as well as the
media from the conditions of the reflex.

About this time Bruecke's attention was directed to this
subject by accidentally observing a young man's eyes be-
come luminous, and in 1817 he invented independently the
same method as that of Cumming. He also mentioned an
observation of Erlach that eyes could I)e made luminous by
the bright light reflected from his concave spherical spectacle
glasses, a fact which Bruecke substantiated by experiments
with others.

To return a moment to another aspect I must point out
that as early as 1701 Mery observed that the fundus of cats'
eyes became distinctly visible when the animal was placed
under the water. La Hire explained this phenomenon five
years later: " When a normal eye is in the air the rays of
light issuing from a point in the fundus are so refracted that
they leave the eye in parallel lines. For this reason we
should be able to see the point in the fundus clearly, for
parallel or almost parallel rays always produce a distinct
perception in our eye; nevertheless, we do not see the ob-
ject. On the other hand, when the eye is under water the

244

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 135.

rays leaving the eyeball diverge and in passing from the
water into the air they are made to diverge still more. The
result is that wherever we place our eye these divergent rays
give us a clear picture of the point in the fundus from which
they emerge." He does not attempt to explain the problem
why the parallel rays emerging from an eye exposed to the
air cannot be seen.

La Hire's profound statement was too advanced, others
receded from it and it required almost 150 years before the
problem was solved.

In 18.51 a little pamphlet was published by Helmholtz,
then a young professor of anatomy and physiology in Koe-
nigsberg, under the title of " Besehreibung Eines Augen-
Spiegels zur Untersuchung der Netzhaut im Lebenden
Auge." ' In this he demonstrated the fundamental fact that
the rays pass out of the eye in the same lines in which they
have entered. He explains Cumming's and Bruecke's obser-
vations as being due to the fact that the eye is not exact
focus for the light and thus rays pass out by lateral disper-
sion. But what was most important, he added the practical
to the theoretical and described an instrument with which the
details of the retina could be examined. He described the
ophthalmoscopic appearance of the retina, calculated the en-
largement under which it is seen, pointed out the value of
the instrument as a measure of the refraction and of the
accommodative changes of the eye. He called attention to
the important physiological observation that fibres of the
optic nerve are insensitive to light. His short monograph
was thorough and complete and gave into our hands a means
of examination of which no one had yet dreamed.

In his modest way Helmholtz thus prophesies its useful-
ness. " I do not doubt, judging from what can be seen of
the state of the healthy retina, that it will be possible to
discern all its diseased conditions, so far as these, if seated
in other transparent parts, such as the cornea, would admit
of diagnosis by the sense of light. Distention or varicosity
of the retinal vessels will be easily perceptible. Exudations
in the retinal substance or between the retina and choroid,
will be seen precisely as in the cornea, by their brightness
upon a dark ground. Fibrinous exudations, usually much
less transparent than the ocular media will, when lying
upon the fundus, considerably increase its reflection. I be-
lieve also that turbidity of the vitreous body will be deter-
mined with greatly increased ease and certainty. In brief,
I do not consider it an overstrained expectation that all the
morbid changes of the retina or of the vitreous body that
have been found in the dead subject will admit of recogni-
tion in the living eye; an expectation that appears to prom-
ise the greatest progress in the hitherto incomplete pathology
of the organ."

How peculiarly applicable are the lines of Weir Mitchell :

" How keen the wind thrill of delight
When some new sun illumes our lessening night,
And problems, dark for many a weary year.
Shine, simply answered — luminous and clear."

' From certain statements in Michaelis' Life of v. Graefe (Berlin, 1877,
p. 34) it would appear that the invention was really made in 1850.

The invention of this instrument ushered in a new era in
ophthalmology the most important and the most prolific era
in the history of this science. The influence it has wielded
upon other branches of medicine is far-reaching. It will not
be out of place to tell the story of the invention of the in-
strument in Helmholtz's words: "I was endeavoring to
explain to my pupils the emission of reflected light from the
eye, a discovery made by Bruecke, w'ho would have invented
the ojjhthalmoscope had he only asked himself how an optical
image is formed by the light returning from the eye. In
his research it was not necessary to ask it, but had he asked
it, he was just the man to answer it as quickly as I did and
to invent the instrument. I turned the problem over and
over to ascertain the simplest way in wliich I could demon-
strate the phenomenon to my students. It was also a remi-
niscence of my days of medical study that ophthalmologists
had great trouble in dealing with certain cases of eye dis-
ease, then known as black cataract. The first model was
constructed of paste-board, eye lenses, and cover glasses
used in the microscopic work. It was at first so difficult to
use that I doubt if I should have persevered, unless I had
felt that it must succeed; but in eight days I had the great
joy of being the first who saw before him the human living
retina."

Helmholtz called his instrument " Augenspicgel "" which
was at first rendered into English as " eye speculum." The
term ophthalmoscope, as Hirschberg wittily says " was given
to the German instrument in France by a Greek " (Anagnos-
takis, 18.54). The name ophthalmoscope has likewise been
applied to an invention of Cramer for studying tlie lenticu-
lar reflexes, afterward called phacoscope by Bonders. You
will find the term ophthalmoscopy in the older works (Himly
Desmarres, Wharton-Jones) to signify the examination of the
eye for the purposes of diagnosis.

Passing from the name to the instrument itself it may not
be superfluous to say a few words in the way of description,
for the instrument has now become very rare. You see that
it consists of a little metal chamber closed in front by sev-
eral plates of glass set at an angle. In the back there is a
space for the insertion of spherical lenses. The instru-
ment is adapted only for close work, for what is known as
the direct method, by means of which the fundus is seen in
upright image. As such it is a perfect instrument optically
speaking and it has been employed for some of the best work
ever done.

It is interesting to learn how the instrument was received.
In Germany it immediately attracted attention. Graefe was
one of the first to recognize how invaluable it would be. His
biographer Michaelis tells us that "when he first saw not
only the red reflex but also the individual parts of the fun-
dus, his eyes sparkled, his cheeks became flushed and he ex-
claimed enthusiastically ' Helmholtz has opened a new world
to us ' — and then he thoughtfully added ' how much there
will be to discover there.' " Arlt procured an instrument
immediately but he tells us in his autobiography that he had
great difficulty in mastering it. Euete, Bonders, Coccius,

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

245

Stellwag and a great number of others busied themselves
with it and soon added import;int contributions.

In France it was likewise taken up eagerly and Leber tells
us that it was so highly thought of that a Frenchman spoke
of it " as a German invention that was so beautiful that it de-
served to have been made by a Frenchman."

The earliest mention that I can find in English literature
is an account in the Monthly Journal of Medical Science in
July, 1853. W. R. Sanders here describes Helmholtz's eye
speculum and the Bonder's Epken's modification. An ex-
cellent article appeared in October, 1854, in the British and
Foreign Medical Review, by Wharton Jones. In this he re-
views the original contribution of Helmholtz and those of
Ruete, Coccius, Anagnostakis Van Trigt, and Eduard Jaeger.
It is here likewise that he mentions the following interesting
account : '"' It is but Justice that I should here state however
that seven years ago Mr. Babbage showed me the model of
an instrument which he had contrived for the purpose of
looking into the interior of the eye. It consisted of a bit of
plain mirror, with the silvering scraped off at two or three
small spots in the middle, fixed within a tube at such an
angle that the rays of light, falling on it through an opening
in the side of the tube were reflected into the eye to be ob-
served and to which one end of the tube was directed. The
observer looked through the clear spots of the mirror from
the other end. This ophthalmoscope of Mr. Babbage we
shall see is in principle essentially the same as those of Ep-
kens and Bonders, of Coccius and of Meyerstein, which
themselves are modifications of Helmholtz."

What a pity that Babbage did not devote a little more
time to this invention ; he could hardly have missed being the
inventor of an instrument whose value is a thousand times
greater than tliat of all the calculating machines ever in-
vented.

The earliest account of the ophthalmoscope in America is
the review of Sanders mentioned above, and reprinted in the
American Journal of Medical Sciences, July, 1853. One of
the earliest accounts and one especially interesting to us is
the report given by the committee on surgery (Brs. Chris-
topher Johnson, Richard McSherry and Joseph AVilkins) to
the Medical and Chirurgical Faculty of Maryland on June
7, 1854. The writer (probably Christopher Johnson), gives
an account of the subject, far from good — but we are inter-
ested in learning that he "experimented with Helmholtz's
speculum in Berlin with von Graefe, in Paris, with Besniar-
res, and in Baltimore, with Prof. G. W. Miltenberger.'' He
illustrates the paper with colored drawings — which had bet-
ter been left out.

Let us now take up the modifications of the instrument.
The first was by Bonders and Epkens in Holland in the
same year, 1851, in which Helmholtz's publication appeared.
The modification consisted in using a plain silvered mir-
ror in place of the plates of glass.

As mentioned before, Helmholtz's instrument was adapted
only for the upright method. In 1852 Prof. C. G. Theod.
Ruete of Goettiugen published a short paper in which he

described the following modification: He replaced the plates
of glass as reflector by a perforated concave silvered mirror
about three inches in diameter and examined the eye from a
distance, placing concave and preferably convex spherical
glasses before the eye examined. In this way he obtained an
inverted image of the fundus and thus it was he who practi-
cally introduced the important method of examination
known as the indirect method." This method reveals the
fundus much less highly magnified, but it has the advantage
of giving a much larger field, and in this way it supplements
the direct method in much the same way as the examination
with high and low powers of the microscope supplement each
other. Ruete's invention is really the only important addi-
tion that has been made to Helmholtz's method and it is
therefore one which deserves special praise. Ruete des-
cribed a few pathological cases examined by means of his in-
strument; these so far as I am aware are the first on record.

His publication called out a second paper by Helmholtz,
entitled " Ueber zine Neue Einfachste Form des Augenspie-
gels," in Vierordt's Archiv, 1853, p. 827.

In this article Helmholtz thoroughly explained the opti-
cal principles upon which Ruete's method depended and then
he described his simplest form of ophthalmoscopic examina-
tion which required only a candle and a strong convex lens.
The observer's head is placed close to the candle but shaded
from it and the lens held near the eye examined. This, and
Ruete's method he showed were practically identical. He
also mentioned an addition to his instrument by the cele-
brated instrument maker of Koenigsberg, Rekoss. The in-
sertion of correction glasses in the old instrument was
tedious and annoying. Rekoss placed two discs which had
lenses in their periphery in the same instrument; by turn-
ing these the lens desired could be obtained." This device,
the Rekoss disc, has been used in most modifications of the
instrument.

In 1853 Coccius invented a modified instrument which for
a time was very popular; it was von Graefe's favorite. It
consisted of a plain mirror upon which the light thrown
through a convex spherical glass attached to the instrument.

None of these instruments, however, equaled in usefulness
the one described the following year by Eduard Jaeger.
This was essentially a Helmholtz instrument in which there
were two reflectors, one composed of plates of glass, like
Helmholtz's, the other a concave mirror; the former was
used for the direct, the latter for the indirect meihod of ex-
amination.

The invention of new forms of ophthalmoscopes now be-

"> In his original communication Ilelmlioltz discusses tlie possibility of
using convex lenses and oijtaining an inverted image. He used two
convex lenses, one placed in the position usually talcen by the concave
lens in the b-ick of the ophth.almoscope, the other at a distance which
was less than the sum of the focal distances of the two lenses. The
latter lens was close to the eye of the observer. This method was very
impracticable and differs essentially from that of Ruete in that the
mirror is placed between the collecting lens and the observed eye.

3 Each disc contained four lenses, one those from 0 in. to '.I in., the
other those from 10 in. to 13 in., all concave.

246

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

came a favorite employment of oplitlialmologists. As mir-
rors, we find the following:

1. Plates of glass as in Helmholtz's instrument.

3. Plain, concave and convex mirrors of silvered glass or of
polished metal with central opening.

3. Plain and convex mirrors upon which light was thrown
through convex spherical glasses.

4. Prisms.

5. Concave and convex spherical glasses, acting at the
same time as correcting glass and as reflector. These were
known as Heterocentric. If other reflecting surfaces could
have been found they doubtless would have been used.

Next the inventive genius of ophthalmologists devised
methods of combining the parts, the illuminating lens and
the mirror, the mirror and the collecting lens required for
the inverted method; and finally instruments were con-
structed in which all the parts were more or less fixed, the
so-called stationary ophthalmoscopes.

Then again it was found necessary to have a greater num-
ber of correcting lenses in the ophthalmoscope, in order to
measure the refraction more accurately and a legion of in-
ventions appeared in which one, two or three Eekoss discs or
combinations of such discs were employed to give the requi-
site array of intervals. The most ingenious of these is the
well-known instrument of Dr. Loring, who at one time prac-
tised in this city.

Finally, Cooper invented an endless chain of lenses to re-
place the Eekoss disc and thus freed himself from the limi-
tations of a wheel which could not be made very large and
therefore could not contain many lenses unless they were
made exceedingly .small. The popular instrument of Morton
is a modification of this.

The endeavor of late years has chiefly been in the direc-
tion of lighter instruments and more convenient ones.

I must not omit to note that a number of ophthalmoscopes
have been constructed in which the source of light is a small
electric light within the instrument. Mention should also
be made of a number of ingenious methods for the determi-
nation of refraction by the inverted method. But I dare not
spend any time in considering these here.

However, there is one subject, the use of the ophthalmos-
cope for skiascopy or the shadow test, which I dare not pass
over. The phenomenon upon which it is based was first ob-
served by Bowman, later by Cooper and was developed by
Cuignet and Parent. As a method for the objective deter-
mination of refraction it is of high value.

It is hardly necessary to ask what has been accomplished
by means of this invention of Helmholtz. The answer
would be: All that Helmholtz prophesied and much more.
What has become of that great category of diseases known
as amaurosis, conditions defined by Philipp von Walther as
those in which the patient saw nothing — and the doctor
nothing too? In Ruete's Lehrbuch published in 1853 I
find 37 varieties of amaurosis, few of the names are intelli-
gible. In their place we now find the many varied diseases
of the retina, of the optic nerve and of the choroid.

It was found that not only were there many varieties of
rclinitis, neuiilis and clioroiditis, as well as degenerative pro-
cesses of the same tissues, but that these changes were often
more or less characteristic of different constitutional and
organic diseases, such as nephritis, diabetes, syphilis, etc., of
leucemia, of cardiac and general vascular disease.

In consequence an important subject developed — that of
the relation of ophthalmology to general medicine, and the
ophthalmoscope became an instrument of great service to the
student of general medicine. Then again the diseases of
the optic nerve were found to have important bearings on
brain and sjiinal cord diseases and thus we find the old
amaurosis cerebralis and the amaurosis spinalis replaced by
the varieties of neuritis and of optic nerve atrophy, charac-
teristic of tumors of the brain, of meningitis tabes dorsalis,
etc. It is not surprising therefore that the ophthalmoscope
became of supreme importance to the neurologist and that an
enthusiastic Frenchman called the method of examination
cerebroscopy (Bouchut). But nothing emphasizes this state-
ment more strongly than that one of the best works on oph-
thalmoscopy was written by a neurologist (Gowers).

I should like to refer to the lessons which the ophthalmos-
cope has taught the pathologist in the study of embolism, of
thrombosis, etc., but time will not permit.

There is one point which I dare not omit: the ophthal-
moscope has been the means of making examinations of the
eye accurate and through its means tliis branch of medicine
has made a great step in advance toward that ideal, tlie ele-
vation of medicine to an exact science.

It is necessary also to mention that the methods of exami-
nation of other parts of the body by means of mirrors as in
otoscopy, rhynoscop3^, etc., likewise owe their origin to Helm-
holtz. It is not generally known that in his original commu-
nication he especially mentions the use of the mirror for the
examination of the nose and of the drum-head.

I shall conclude with an extract from an address by Helm-
holtz, delivered on the occasion when the Graefe medal was
awarded him by the ophthalmic society of Germany (188G).
This adds lustre to the invention through the modesty with
which he regarded the part he played.

" Let us suppose that up to the time of Phidias nobody
has had a chisel sufficiently hard to work on marble. Up
to that time they could only mould clay or carve wood. But
a clever smith discovers how a chisel can be tempered.
Phidias rejoices over the improved tools, fashions with them
his God-like statues and manipulates the marble as no one
has ever done before. He is honored and rewarded. But
great geniuses are most modest just in that in which they
most excel others. That very thing is so easy for them that
they can hardly understand why others cannot do it. But
there is always associated with high endowments a corre-
spondingly great sensitiveness for the defects of one's own
work. Thus says Phidias to the smith ' without your aid I
could have done nothing of that; the honor and glory belong
to you.' The smith can only answer : ' But I could not have
done it even with my chisels, whereas you, without my chisels

AncusT, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

247

could at least have moulded your wonderful works in clay;
therefore I must decline the honor and glory, if 1 will remain
an hiinorahh" num.' But now Phidias is taken away, and
there remain his friends and pupils Praxiteles, Paionios and
others. They all use the chisel of the sinith. The world is
filled with their work and their fanu\ They determine to
honor the memory of the deceased with a ji'arland which he
shall receive, who has done the most for the art, and in the
art, of statuary. The l)eloved master has often praised the
smith as the author of their great success and they finally
decide to award the garland to him. ' Well,' answers the smith.
'I consent; you are many and among you are clover people.

I am but a single man. You assert that I singly have been
of service to many of you and that many places teem with
sculptors who have decked the temples with divine statues,
which without the tools that I have given you, would have
been very im])erfeetiy fashioned. I must believe you, as 1
have never chiselled nnirhle and I accept thankfully what you
award to me. hut T myself would have given my vote to Praxi-
teles or Paionios." '' '

••At the conclusion of the above address a number of old ophthalmo-
scopes, incliuUnp; an oriu:inal Heluiholtz ophthalmoscope and a number
of old publicatinns were demonstrated.

THE FIRST NEPHRECTOMY AND THE FIRST CHOLECYSTOTOMY, AVITH A SKETCH OF THE
LIVES OF DOCTORS ERASTUS B. WOLCOTT AND JOHN S. BOBBS.

By Martin B. Tinker, M. D.,
Assistant Bcsident Surgeon. The Johns Ilapl-ins Hospital.

As a rule, men of science and letters of all nations speci-
ally delight to honor those of their own countrymen who
have added noteworthy contributions to the sum of hunuiu
knowledge. In medicine, particularly, we see much of this
pride in national achievement. To the loyal German student
of medicine nearly everything worthy of mention seems to
have been accomplished by Germans; the same is true of the
Englishman and of the Frenchman. The American medical
[irofession, however, seems to be somewhat of an exception
to this rule. It is true that we are still young as a nation
and have not yet had time to accomplish as great results as
the older nations, but decidedly too little is known about
that which has been already accomplished among us. We
know too little of those whose achievements in most other
countries would be well known to all their countrymen. The
object of this paper is to bring to your attention some facts
about two pioneers in American surgery whose names and
work are not as generally known and honored in the American
medical profession as I believe they deserve.

The first nephrectomy was performed by Dr. Erastus B.
Wolcott, of Milwaukee, June 4, 18G1. I am unable to find
that he ever formally reported the operation, but the follow-
ing account of the facts of the case are given by Dr. Charles
L. Stoddard, of E. Troy, Wisconsin, in the Philadelphia
Medical and Surgical Eeporter for 1861-63, Vol. VII, page
120. The title is " Case of Encephaloid Disease of the Kid-
ney, Removal, etc." With the exception of a few unnecessary
details, I quote in full:

" On the 4lh of June last I was invited to assist Dr. E. B.
Wolcott, of Milwaukee, in the removal of a tumor from the
abdomen of Mr. J., aged 58 years. On examination we found
that the patient was a tall, anajmic looking man of a peculiar
cast of countenance, indicative of serious organic disease.
He stated that he was of healthy parentage, and had good
health until the appearance of the tumor six years before

that time. The physician in attendance stated that from
the first appearance of the disease, some irritation of the
urinary organs had existed, but what the deposits were wc
were unable to learn, as no reliable cliemical or microscopical
evidence was presented.

We found the tumor to be large, filling the right hypo-
chondriac region and pressing the abdominal parietes for-
ward about two inches from their natural level. On palpa-
tion it was evident that it was semi-solid, having a pedicular
attachment, apparently to one of the sulci of the liver, with
more extensive attachment to the posterior parietes.

Having no reliable data to form a diagnosis, other than
the present state, after duly considering the patient's anxiety,
and his deprivation of general health, we concluded that an
operation offered the only chance of ultimate recovery; at
the same time we stated to the patient and his friends that
the operation was a serious one in his state of health. Our
conclusion was, that we had here a cystic tumor of the liver,
pressing on the kidney and producing irritation sufficient to
account for the albuminous deposit. After the administra-
tion of chloroform. Dr. Wolcott proceeded to the removal of
the tumor by making an incision diagonally across it down to
the peritoneum, which we found to be very much thickened
and slightly attached to it. He then proceeded to free it
from its extensive posterior attachments, after which he
found that the superior attachment was a very dense cord-
like structure, about an inch in circumference, and appar-
ently proceeding from the posterior part of the liver.

Carefully tying the pedicle, he severed this connection
with a knife, and after removing foreign matter carefully
from the abdomen, brought the edges of the wound together
with common sutures and adliesive strips, which was the only
dressing used. After the patient was free from the effecls
of chloroform, morphia and camphor were administered in
sufficient quantities to quiet irritation and produce sleep.

248

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

The tumor weighed 2i pounds, and on incising it freely,
we found undoubted evidence of its being a kidney from a
small portion of its upper portion, which had not degener-
ated, showing the tubules and a portion of the pelvis.

The patient lived 15 days after llu^ operation, and dicil
apparentl}' from- exhaustion, caused by the great amount of
su])])uration which necessarily followed."

It is interesting to note that as early as the 17th century
nephrectdmy had been dune cxjierimentally on dogs. In an
article in von Pilha and I>illroth's System of >Surgery, Hei-
ueeke states that Zambcccarius in the latter part of the 17th
century removed a kidney from a dog and the animal re-
covered. This was done after he liad observed at dissections
that some healthy dogs have only one kidney.

llhincard, of Amsterdam, in his "Lexicon medicum reno-

ERASTUS B. WOLCOTT, M. D.,
Boni October IS, ISIM. Died .].iiuiarj' .i, ISSO.

vatum," published in 17.'>fl, also mentions experimental neph-
rectomy and believes that it might be perforined on man.

Simon, of Heidelberg, is generally credited with having
performed the first nephrectomy, but his operation, reported
in Deutsche Klinik, Berlin, 1870, was not performed until
eight years after Wolcott's operation. Simon undoubtedly
deserves greater honor for having done nephrectomy experi-
mentally on dogs, for undertaking the operation deliberately,
knowing what he had to deal with and for bringing the opera-
tion before the medical profession, but the honor of priority
is in no wise due to him, for Wolcott's operation was per-
formed in 1861, more than eight years previously.

Erastus B. Wolcott was born at Benton, Yates Coimty,
New York, October 18, 1801. He was fortunate in his
ancestry, coming from a race of unusually intellectual and
enterprising men and women. He was the son of Elisha and
Anna Hull Wolcott, who came from Litchfield County, Con-
necticut, and were among the first settlers of that section of

New York. The Wolcott family were from good old English
stock. Henry Wolcott came to America in 1G3U, and his
descendants in a direct line for over 180 years were among the
most prominent of the colonists. Their names are found
among the officers of the Colonial army, one was a signer of
the Declaration of Independence, six were governors of the
state of Connecticut, and there were many senators, repre-
sentatives and several justices of the Supreme Court.

Dr. Wolcott's early life was like that of most children on
the frontier in those days. Educational and social advantages
were few, but the life of a frontiersman developed healthy
bodies and minds. As a boy he attended the public schools,
but I am unable to find that he had opportunities for higher
education. In those days it was the custom for young men
who desired to practise medicine to begin their studies with
some practising physician, and Dr. Wolcott began the study
of medicine and surgery with Dr. Joshua Lee, one of the most
eminent men in his profession in central New York at that
time. After three years' study with Dr. Lee, Dr. Wolcott
received his qualification to practise medicine from the Yates
County Medical Society in 1825. He was desiroiis of further
study, and in order to earn money accepted a position as a
surgeon to a mining company in South Carolina. He lived at
the mines and in Charleston until 1830, when he ret\xrned to
New York and attended the College of Physicians and Sur-
geons of the Western District of New York from 1830 to
1833, and from this institution he received the degree of
Doctor of Medicine. In 1835 he took the examination for
surgeon in the United States Army, and received his appoint-
ment January 1, 1836. He was stationed at Fort Mackinaw,
where he met his future wife, Elizabeth J. Dousman, the
daughter of a fur-trader at that post. He resigned his posi-
tion in the army in 1839 and settled in Milwaukee, where he
]iractised medicine for over forty years.

Personally, Dr. Wolcott was a man of remarkable physique.
He was early noted for his great strength, and when a young
man it is said that he could run and jump over a team of
horses. He was also an expert shot with a rifle, shotgun or
bow. His father came into the possession of an unusually
strong bow once owned by the Indian chief Red Jacket. It
is stated that very few white men could draw the bow to its
maximum power, and not one in a thousand could use it
skilfully. It is reported in the history of Yates County, New
York, that Dr. Wolcott shot a blunt square-ended arrow
through the siding of the first Methodist meeting-house of
that county, at a distance of twenty rods. The church had
been at that time abandoned. Dr. Wolcott retained his
physical powers even to the time of his death. When seventy-
five it is said that he could vault a five barred fence or shoot
a pigeon on the wing as well as when a boy. During the last
summer of his life he was called to a town at some distance
to see a patient. He was desirous of reaching home as soon
as possible and boarded a freight train which happened to be
the first train going to Milwaukee. Finding that the train
would be unavoidably delayed, he walked from the town,
eighteen miles distant, to Milwa\d\ee, and arrived some time

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

249

before the train. When he was asked why he did so he
stated that he was in something of a hnrry and that he wanted
to see if he was really growing old.

He was a man of unusual strength of cliai-ai'ler and intel-
lectual attainments and made up for the hulv of a liberal
education by a wide reading. All the records which we have
of him specially mention his generosity. Nothing in the way
of fatigue or hardship ever prevented immediate attention to
a professional call, no matter what the flTiancial standing of
the patient might be. At the time of his death thousand.-;
of poor people gathered from the city and surrounding
country to honor his memory, and the arcade in wliicli he
lay in state was choked by the middle and lower classes.
His great professional ability and personal popularity
brought him into many public positions. He was surgeon-
general "F the state of Wisconsin as early as 1M2, which
office lie held during the ('i\il AVar and to the time of
his death. He was a inemljcr of the ]'>oard of Regents ot
the state uui\ci'siiy, a manager of the Soldiers' National
Home at Milwaukee, major-general ol' the state militia,
trustee to the Wisconsin Hospital for (he Insane and
commissioner to the Paris Exposition. As a consulting
surgeon he was well known throughout th.e Nortliwestern
states, and he was frequently called long distances in
critical eases as a consultant. Dr. Wolcott's surgical
achievements were not limited to performing the first
nephrectomy. Among other operations which he performed
and about which I have received definite personal informa-
tion were: excisions of the breast, trephining, thoracotomy,
an extensive plastic for the scar of burns which had fixed
the chin to the chest, oophorectomy, Caesarian section and
many other major operations, some which were quite unusual
in his day. It should be remembered that frontier surgeons
of that day operated without the advantages of the modern,
thoroughly equipped hospital, without the aid of trained
assistants and not infrequently without any assistant; anti-
sepsis was almost unknown and anaesthetics were just being
introduced. The esteem in which he was held by his fellow
citizens is shown by the fact that his funeral procession was
led liy six hundred veterans from the state of Wisconsin and
that resolutions of sympathy were passed after his death by
the Jlilwaukoo Academy of Medicine, Milwaidvee County
Medical Society, and by numerous clubs and military associa-
tions. Several pi'oniinent medical men from the section in
which Dr. Wolcott practiced have recently told me that they
consider liim the greatest surgeon the middle West has ever
|)roduced. and hundreds of people gi-atefully remember him
as their benefactor and friend.

The tirst cholecyslotoniy was jierfornieil liy dolin Slough
Bol)bs, of Indiana|)olis, Indiana, June |."i, 1S(17. A re[]ort
of the case may lie round in Hie 'i'ransactioiis of the Indiana
Jlcdical Society tor ISdS. The chief features of the case are
as follows:

A woman, 30 years of age, came to l)i'. Hobbs in consul-
tation with her physician. Four years previously she had
noticed an cnlarKcmwit in the rijiht side which she stated was i

low down in the iliac region. Her health at that time was
bad. She had ]jain and distress on taking food or drink or
after exercise, which frequently continued three or four hours.
The enlargement in her side continued to increase and soon
became tender. Ultimately it prevented her from walking,
and following January, 1867, the increase in size was more
rapid and the trouble was greater. On examination a tumor
was found in the right side wdiich was tender to pressure.
Its outline could not be well made out except on the right
side, where it was quite distinctly defined. The tumor was
slightly movable, and the abdomen was tense and slightly
projecting. Vaginal examination disclosed no connection
with the uterus or its appendages. The patient was exceed-
ingly anxious to have something done for hei' I'clief. A
diagnosis of ])robahle ovarian tumor had been nuide by sev-
eral physicians, but after observation for a considerable time
the patient was informed that the true nature of the growth
was uncertain and she was given no assurance that it could be
successfully removed. The patient, however, persisted in her
request that an operation shordd be undertaken, and an
exploratory celiotomy was made by Dr. Bobbs, assisted by
several local jihysicians. Under chloroform aniPsthesia an-
incision was made between the lunbilicus and the ]ud)es.
The omentum was found thickened and adherent to the
abdominal wall. It was separated toward the right side in
hope of reaching some part where no adhesions existed, but
failing in this, the omentum was torn through over the
tumor so as to admit the finger upon the protuberant portion
of it. Passing the finger arormd the mass some adhesions
v.-ere broken np and the tumor was traced upward. No
pedicle or attachment could at first be definitely made out.
The abdominal incision was then carried above the und)ilicus
on the right side over the prominent part of the enlargement.
The mass was oval in form, tense and contained ])ellucid
fluid. An incision was made into it and perfectly clear fluid
escaped with considerable force, ]U'opclliug several gall-stones
about the size of an ordinary rifle bullet. On inti'oducing
the finger other solid bodies were felt, but not in the main
sac. A number were hooked out with the finger from this
sac. They varied in size from that of a mustard-seed to
that of a bullet. No communication between this sac and
the main sac could be found. The second sac had the
appearance externally of a hydatid cyst, its walls were of the
thickness of the skin, and its inner covering was smooth and
v.hitish. Pulling it downward the right lobe of the livei
was brought into view, to the lower surface oC which the sac
was attached by a broad linear base like the gall-bladder.
At first there was some doubt as to whether the sac was
really an eidarged gall-ldadder, but this seemed to lie defi-
nitely identified by its form, attachments and tlie concretions
which it contained. The sac was then closed by stitches, tlie
nature of which is not mentioned and the alidcnninal wound
was sutured. At a dressing one week aflei' the ojieration a
stitch abscess was found which had given the ]iatient some
pain and discomfort for a few days after the operation. From
this time, however, the patient's recovery was uneventful,

250

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 135.

and at the end of two weeks she was permitted to sit up, and
in three weeks she was about the iioiise. A complete I'eport
is given of tlie progress of tlie patient from day to day, but
the essential points have been noted. In an editorial article
which appeared in the Indiana Medical Journal in October,
1899, it is stated that the patient is still living near Indian-
apolis, thirty-two years after the operation, and in answer to
a letter of inquiry from the editor of the Indiana Medical
Journal, she writes as follows: " My gall-bladder was opened;
between 40 and 50 stones were removed; there was a partition
dividing one from the rest and that one was left; the size of
the stones was from a shot up to a pea. I was informed that
the bladder was sewed up. As to the doctors present I can
remember seven, but they have all passed out but one." The
names of the doctors are mentioned and the letter closes with

JOHN S. BOBBS, M. D.,
Born Uecembef 2b, ISO!). Died May 1, ISTO.

the statement that the patient still has some trouble, which
she thinks is caused by the one stone which was not removed.
John Stougli Bobbs was born at Green Village, Pennsyl-
vania, December 28, 1809. I have been unable to find very
much information about his early life or education. In a
memoir by Ur. P. H. Jameson, published in the Transac-
tions of the Indiana State Medical Society, 1894, it is
stated that Dr. Bobbs was of Pennsylvania German descent.
As a child he s]>oke the peculiar dialect of that section.
He was a man well educated in the fundamental branches,
he wrote English well and was a fluent speaker. He was
also well versed in history, he had a good knowledge of
the English classics, and had given some attention to
philosophical writings. At the age of 18 he began to
read medicine with Dr. Martin Luther, of Harrisburg.
After this he attended one course of medical lectures and
then located in Middletowu, Pennsylvania, where he prac-

tised for four years. He located in Indianapolis in 1835,
but took a course of lectures in Jefferson Medical College in
Philadelphia the same year, graduating in the spring of 183G
after two courses of lectures and study with a preceptor as
was required in tliose days. He soon took high rank both as
a physician and surgeon. When the Medical College of
Indiana was organized he was elected professor of surgery
and later dean of the faculty. As a practitioner, one of his
contemporaries states that there was less sham about Dr.
Bobbs than any physician he ever knew. Up to the time of
his death he had never been known to give a placebo in any
case and his treatment was based upon rational lines. Once
when called to see a patient suffering from an acute malady,
he suspended all medical treatment, giving only stimulants
and foods. When questioned about his course of treatment
he said: "Why give medicine here without a reason or a
purpose for it? " The patient recovered and was still living
and well at last accounts. Dr. Bobbs believed strongly in an
organized and united medical profession and labored faith-
fully with that end in view. He was first in the work of
establishing the Marion County Medical Society in 1847, and
he was prominent in helping to organize the state society of
Indiana in 1849. In both societies he was an active and
prominent member. In 1868 he was elected president of the
Indiana State Medical Society. His inaugural address was
upon " The Necessity of a State Medical Journal and a
Medical College." His paper on lithotomy of the gall-
bladder, from which my report of the operation is taken,
was published in the same volume of the transactions with
his presidential address. The latter part of Dr. Bobb's life
was devoted mainly to surgery. He was well read in the
literature of his specialty, and as an operator he was bold and
original. Like most of his contemporaries, lie was not a
frequent contributor to medical literature. Dr. Jameson, in
the paper which I have quoted, mentions an operation in
which he assisted, in which Dr. Bobbs removed the superior
maxillary bone together with the eye of the affected side for
extensive carcinoma. The operation lasted several hours,
but the patient made a good recovery. The haemorrhage
was so well controlled that little blood was lost and the pa-
tient recovered from the operation and was much more com-
fortable afterward. He also mentions a successful operation
for extra-uterine pregnancy and an unsuccessful o])eration
for umbilical hernia. Dr. Bobbs was a brigade surgeon dur-
ing the Civil War, and in the latter oflice he was medical
director for the district of Indiana. During the Civil War
he was with the staff of General Morris, of Indianapolis, and
showed his courage by bringing olf the field under fire a
soldier who was fatii.lly wounded.

Besides his i>rpfessional services. Dr. Bobbs was a public-
spirited man who look an active part in tlie afl'airs of his city
and state. For one term he served as state senator. He was
one of the original commissioners who organized the Indiana
Hospital for the Insane, and ho gave liberally to general
charitable purjtoses. In jierson he was slender, of medium
height with striking features. His forehead was high, his

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

251

eyes dark grey, his nose large and aquiline, his chin promi-
nent. He generally wore a suit of black broadcloth and a
silk hat, and had the manners of the old-style gentleman.

He may be truly considered one of the founders of scien-
tific medicine and sui'gery in the middle West. As the
greatest general surgeon and teacher of his day in that sec-
tion of the country, as a public-spirited man and soldier, his
name will long be remembered in the region in which he
practised.

Several others Itesides Bobbs did valuable pioneer work in
gall-bladder surgery, but there is no evidence that I have
been able to find that any one, at an earlier date, ever opened
the gall-bladder after celiotomy.

Johannes Fabrieius is credited with having opened the gall-
bladder and removed stones from it as early as 1618. Fabri-
eius Hildanus refers to this in his " Observations chirur-
giques," published in Geneva by P. Chouiit in 1GG9, but there
is no evidence which would lead us to believe that this was
an operation performed on a living person.

Among the older surgeons, Jean Louis Petit did most to
clear up the symptomatology of the diseases of the biliary
jiassages and to differentiate between these and intra-abdom-
inal sui)purative affections. In tlie Memoirs de I'Academie
Royal de Chirurgie, Paris, 174.3, Vol. I, p. 1.55, he mentioned
three cases in which the gall-bladder was incised by mistake
as an abscess, one of the patients recovering. From post-
mortem study of several patients that died of the results of
gall-bladder disease, he decided that the recovery in this case
was due to adhesions to the abdominal wall. He advised
lithotomy of the gall-bladder in cases in wbicli it seemed

likely that such adhesions were present, provided the patients
were extremely ill and in danger of death, but he does not
mention having performed any operation which can be prop-
erly classed as a cholecystotomy. Numerous others advised
and performed tapping, and several recommended abdominal
section, suturing the gall-bladder to the abdominal wall and
opening after several days, but no one seems to have per-
formed the operation.

Some will be inclined to criticise the claims to the honor
of priority for the two men because the operations were
undertaken without a knowledge of the conditions later found.
But I would like to ask, what person who has seen many
operations has not seen some of the best surgeons obliged to
change their diagnosis after opening the abdomen? Because
Columbus set out with a purpose quite different than the
discovery of a new continent, because he died without appre-
ciating the importance of his discovery, is he any the less the
discoverer of America? Both Wolcott and Bobbs were ex-
perienced surgeons, accustomed to perform all the usual major
operations of the surgery of their day. Both opened the
abdomen uncertain what they would meet, but perfectly
understanding that the conditions they had to deal with were
most grave. Both met their difficulties and coped with them
successfully for the first time in the history of surgery so
far as we can learn. While we concede to Simon and to
Sims, Tail, Richter and Roljson the honor of ])lacing the
operation of nephrectomy and the operation of cholecystotomy
on a firm and scientific basis recognized and acknowledged by
our profession, can we Americans afford to let the names of
these two fellow-countrvmen go unnoticed?

MEASUREMENT OF THE EXTERNAL URETHRAL ORIFICE.

By G. Brown- ^Iiller, M. D.

The diameter of the lumen of the female urethra is given
by Gray and Quain as one-fourth of an inch. Billroth and
Luecke and others estimate it at 6-8 mm. So far as I can
learn, no estimate based upon a large number of cases has
ever been made. For the purposes of cystoscopic examina-
tion, catheterization of the ureters and the like, it is im-
portant to know what is the largest cystoscope which can
be introduced without causing injury to the urethra. It has
been found by Dr. H. A. Kelly that in such procedures the
greatest resistance met with in the introduction of the specu-
lum is at the external urethral orifice, and that in a normal
urethra when the speculum passes this point it can be pushed
into the bladder without further resistance. In dilatation
of the urethra within moderate limits practically all of the
laceration which occurs takes place at the meatus urinarius.
It was, consequently, thought important to get accurate
measurements of the diameter of the external urethral orifice.
This was done in the gynecological wards of the Johns Hop-
kins Hospital in 100 cases. The instrument used was the
urethral calibrator (Fig. 1), described by Dr. Kelly in the
American Journal of Obstetrics, Vol. XXIX, No. 1, 1894.

The method as described Ity him is as follows: " I calibrate
the meatus urinarius by means of a slender metal cone, which
is 10 cm. long and marked in a graduated scale from the
point (3 mm.) to its other end (20 mm.) in diameter. The

Fi(.. 1.

calibrator is pushed into the meatus as far as it will readily
go and the marking of the meatus is noted."

I give here in a tabulated form 100 cases taken without
reference to their gynecological ailment and give their age,
disease, number of lahors, and the measurement of the vaginal
outlet. In glancing over the table one will lie struck with
the large number of cases operated upon for laceration of
the perineum or relaxation of the vaginal outlet. This is
accounted for by the fact that the measurements were taken,
as a rule, only in those cases where the external genitalia had
been thoroughly cleansed as preparatory to operation. In
cases of abdominal section the measurements were frequently

252

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

neglected. As seen from the table, this does not, to any
noticeable extent, change the average. The smallest urethral
orifice (4 mm.) was found in a woman who had borne eight
children and who was suffering from carcinoma of the cervix.
The largest urethrae, two in number (12 mm.), were found
likewise in multiparous women. While the average diameter
of the external urethral orifice in nulliparous women was
practically the same (7.8 mm.) as in women who had borne

children (7.6 mm.) yet in cases of extremely relaxed vag-
inal outlet or prolapsus of the uterus, it was found, as could
have been expected, that the meatus was larger than in
those cases where this relaxation did not occur.

The measurements of the vaginal orifices were made by
means of the vaginal calibrator (Fig. 2), also devised by Dr.
Kelly. The cut will explain tlie working of the instrument.
It consists of two slender metal bars crossing eacli other and
working on an axis in their middle. At one end each has a
narrow curved plate and the measure is at the other end.
The plates are introduced into the vagina and separated by
gentle pressure, and the scale measures the diameter of the
gently dilated vaginal orifice. Below is the table.

TABLE.

Age

No. of

Yrs.

Labors

■66

DISEASE.

Prolapsus Uteri

Rblaxed Vag. Outlet

Descensus Uteri

Relaxed Vag. Outlet

(( n n

Pelvic Intlammation

Endometritis

11 ^

Descensus Uteri

No Gjuecological Disease

Relaxed Vag. Outlet. RetroH. Uteri

Rupture of Recto-Vaginal Septum .

Relaxed Vag. Outlet

II " " Retrotl. Uteri. .

Prolapsus Uteri " " . .

R. V. O., Retroll. Uteri, Ovar. Cyst.

Relaxed Vag. Outlet

I' " " Retrotl. Uteri .

Relaxed Vag. Outlet

Carcinoma Cervicis Uteri

Relaxed Vag. Outlet

Rupture of Recto. Vaginal Septum.
RetroH. Uteri, Relaxed Vag. Outlet

uiam.

Urethra

Mm.

Meas.

V^ag'al

Outlet.

Cm.

6.5

7.5

6.5

B.5

4.5

9.75

8.25

8.5

6.5

4.5

TABL'E— Continued.

Age
Yrs.

50
36
32
36
36
38
37
23
30
34
33
35
35
38
39
43
33

No. of
Labors

0
0
4
1
3
0
0
0
0
9
1
0
8
6
4
1
6
3
1
6
1
8
1
4
1
2
4
3
3
1
0
9
U)
1
1
4

4
0
5
0
0
0
4
0
1
5
6
3
0
10

DISEASE.

. g Meas.
B.^Sa' of
S oS5 Vag'al
Q i;^;Outlet.
P Cm.

Endometritis

Retroflexio Uteri ...
Relaxed Vag. Outlet .

Retrotl. Uteri..

Retroflexio Uteri... .
Pelvic Intlammation
Dysmeuorrboea ....

Sypbilis

R"etroll. Uteri. Relaxed Vag. Outlet

Pyosalpinx

Relaxed Vag. Outlet

" " " Hemorrhoids

" Retrotl. Uteri

Laceration of Cervix

" K. V. O. Retrotl. Uteri
Relaxed Vag. Outlet. Retrofi. Uteri

Retrotl. Uteri.

Myoma Uteri

Relaxed Vaginal Outlet. RetroH. Uteri,.

Rupture of Recto-Vaginal Septum

Relaxed Vag, Outlet. RetroH. Uteri

" " " Hemorrhoids

" " " RetroH. Uteri

Myoma Uteri. Retained Secundines..

Dysmeuorrboea

Relaxed Vag. Outlet. RetroH. Uteri..

Prolapsus Uteri

Kelaxed Vag. Outlet

RetroH. Uteri

Laceration of Cervix. . .
Retroversion of Uterus.

Hemorrhoids

Relaxed Vag. Outlet

Dysmenorrhoea

Pelvic InHammation

Appendicitis. RetroH. Uteri

Relaxed Vag. Outlet

Dysmeuorrboea

Relaxed Vag. Outlet

'■ " RetroH. Uteri.

Retroflexio Uteri

Double Vagina. Bicomued Uterus Relaxed

Vag. Outlet

Relaxed Vag. Outlet. Retrofl. Uteri

Retrofl. Uteri.,

Pelvic Inflam.
Hemorrhoids.

Prolapsus Uteri

Relaxed Vag. Outlet. RetroH. Uteri.

Retrofl. Uteri.

Hemorrhoids

Retroversio Uteri.

7.5

8.5

7.5

7.75

6.5

9.5

7
13

9.5

6.5

6.5
10

7
8
7

8
8
8
8
6
6

13
8

10
6

No. of cases, 100.

Average diameter of meatus in 100 cases, 7.59 mm..

Average diameter of meatus in nulliparous women, 7.83 mm.

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

253

ABSTRACT:' THE FREQUENCY OF GALL-STONES IN THE UNITED STATES.

By Clelia Duel Moshek, A. M., M. D.

(SERVICE OF DR. KELLY.)

Gynaecological Extenic in the Johns Hopkins Hospital Dispensary.

(Read before Ike ./o/iiis Hopkins Hospital Iledical Society, Marcli i, 1901.)

Although numerou.s statistics on the frequency of gall-
stones have been published abroad, yet, as far as I know,
there have not been given results based on a large number
of cases in this country.

To determine the frequency of gall-stones in America, at
Dr. Kelly's suggestion and with the permission of Dr. Welch,
I examined the records of 165.5 complete autopsies (Table I)
from the Pathological Department of the Johns Hopkins
Hospital. Of the 1655 records examined 1037 were males
and G18 females; 634 were black and 1018 white; the color in
the remaining 3 cases was not given. In 115 cases, or 6.94
per cent, gall-stones were present. All the percentages are
larger than for my first 1000 cases, which were quoted by
Dr. Kelly." The reason for this has not been found. Both
at Basel published two sets of statistics (Diagram I) in wliicli
a similar difference is observed.

TABLE I.

Frequeiiey of Gail-Stones in Persons of Different Af/ea in 10.5.5 Autopsies,
from the Pathological Department of the Johns Ifopkins Jfospifal.

Ak.

Number of

l»iiticnts.

autopsies.

0-30 .

233

21-30 .

277

31-40 .

333

41-.50 .

328

51-60 .

258

61 and

aver

219

Age uul

uowu . . . .

otals

1655

Number of
cases with
gall-stones.
1
5
18
29
34
28

115

Percf'nta^'-e of cases
e.vaniiiKMi in \vhieb {^all-
stones were pr-esi'nt.
0.43
1.80
5.40
8.84
13.14
12.17

6.94

The percentage of frequency of gall-stones in Germany,
Austria, Switzerland and the United States is shown in Dia-
gram I. It will be seen that the frequency in this country
most nearly corresponds to that given by Rother for Munich.

Naunyn, in his treatise on cholelithiasis, bases most of his
statements on the statistics of Schroder (Table II) who
analyzed the cases from the Strassburg Hospital, where the
autopsies include all periods of life. Prof, von Ivecklinghau-
sen vouched for the fact that in no case had gall-stones been
overlooked. The statistics for this country have been com-
pared with those given by Schroder because of the great
accuracy of the latter and the fact that the more complete
data allowed exact comparison.

1 This paper in full will appear in Vol. X of the Reports of tbe Johns
Hopkins Hospital.

■'Kelly, Dr. H. A.: A Rapid and Simple Operation for Gallstones
found by exploring the Abdomen in the course of a Lower Abdominal
Operation, in Med. News, Dec. 33, 1900.

Diagram I.

Tbe frequency of Gall-Stoues in Germany, Austria and Switzerland as
compared with the United States.

i 1

—

'5+-b:

—

1 ["

SCO

TABLE II. »

Freqnencij of Gall-Stones in Persons of Different Aijes, aecordiny to
Seliroder.

Number of Percentage of cases
cases with e.\amined in which gall-
gall-stones, stones were found.

Age of
patients.

Number of
post-mortems.

0-20

31-30

188

31-40

209

41-50

352

51-60

161

60 and over . . . .

358

Totals

1150

3
6
24
38
16
65

141

3.4

3.3

11.5

11.1

9.9

35.2

Naunyn ascribes the variation in frequency of gall-stones in
the statistics from different portions of Germany: (1) to the
relatively larger or smaller number of young people included
in any given number of eases; or, (2) to gall-stones being

■'Naunyn: A Treatise on Cholelithiasis; London, New Sydenham
Society, 1896.

254

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

overlooked at autopsy. Although in the Johns Hopkhis
Hospital cases there is a somewhat larger proportion of
young people included in the 1655 cases, a careful analysis
shows that this fact fails to explain the much smaller fre-
quency of gall-stones in this country. The second expla-
nation is also inoperative here, as Dr. Welch has stated that
gall-stones had not heen overlooked in any case where they
were present.

Age: Tahles I and II sliow the distribution of the cases
according to age groups.

Naunyn has called attentiim to the relative infrciiuency of
gall-stones before the age of 30 years.

Diagram II shows the distribution according to age of
both the German and American cases. The German cases
are represented by the black line, the American cases by the
red line. The irregularities in the German curve are prob-
ably apparent rather than real, the variation of the number
of cases in each group probably being the reason. In Ger-
many the greatest frequency appears to be after the 61st
year, while in America the greatest frequency occurs between
the 31st and 60ih years. The American cases show a gradual

DiAUIiAM II.

Frequency of Gall-Stones in Geumany as Comi'aued with the
United States iiy Age Groui-s.

Oermany (Schroder), 11.50 cases.
Ihiited fitates, l(i5.5 cases.

/4
/3

—

. .

s ■

-■"

AG£

•

4/-

5/-

'*(

?y/i

Diagram III.

Comparative Freqdenct of Gall-Stones in 1018 Whites and ()34
Blacks by Ages (United States).

mm— Whiles

]

,■

■■

/ 1
/ 1

J>C£

0-20

11-30

3/-40

41-50

SI-60

6liOV£Jt

and almost uniform increase in the percentage frequency to
the sixtieth year. The slight falling off after this age is
apparent rather than real, being probably due to the smaller
number of cases included in this group. These cases tend to
confirm the usual statement that gall-stones are rare before
the thirtieth year and more frequent after that jjeriod.

TABLE III.

Frequency of Oall-Slones in Whites of Different Ages in 1018 Autopsies,

[From the Patlioloyical Department of tlie Johns Hnpliins Ilnsintal].

Age ot

patients.

0-20

3I-yo

.^1-40

41-50

.51-00

01 aiitl over . .
Aire nut liiven

Totals.

Number of
autopsies.

133
1.52
20ti
311
164
14.5

1018

N umber of Percentage of eases

cases having examined in which gall-
gall-stones, stones were iiresent.

4
13
21
30
33

2.63

5. 82

9.95

13.35

15.86

7.85

TABLE IV.

Fretjucnrij of Gall-Stones in Blacks of Different Aijes in 634 Aiftopi^ics,
[From tlic Pathntuaical Dcpartmciit of the Johns Hoplilns Hospital].

Number of Percentage of cases

cases having examined in wliich gall-
gall-stones, stones were present.
1 1. 01
0.8

Ago ot
patieuts.

Number ot
autopsies.

0-20

21-30

125

31-40

126

41-.50

115

51-00

61 and over

Age unUiiiiwu, . . .

Totals

634

4.76

6.91

15 . 05

7.14

5.51

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

255

Eaee: Table III gives the cases of 1018 whites arranged
in age groups, with number of cases having gall-stones and
the percentage frequency in each group; Table IV gives the
cases of (534 blacks, similarly arranged with corresponding
data. Gall-stones occurred in 80 whites, or in 7.85 per cent
of the eases, and in 35 cases, or 5.51 per cent, of the negroes.
Pending a study of a larger series of cases, we must conclude
tliat gall-stones occur somewhat less frequently in the black
tlian in the white race.

Sex: Naunyn states that according to Schroder's statis-
tics 20. G per cent, or about one in every five women, have
gall-stones. A striking difference is apparent in this
country, for gall-stones were present in only 58 cases (9.37
per cent) of the G18 female bodies examined. Therefore, in
this ccmutry only one woman in every 10 ov 11 would appear
to liave gall-stones — a frequency less than half as great
among American as compared with German women.

DUGKAM IV.
('OMPAKATIVE FREQUENCY OF GaLI.-StON'ES IN MaLES AND FEMALES

BT PER CENT OF ALL AGES COMBINED (United States).

^ifi

M.,,,^

fCMAlSS

PifiCm

Diagram V.

CoMI'AltATIVE FliEQUENCV OF GaLL-StONES IN MALES AND FEMALES,

BY PER CENT OF ALL Ages COMBINED (Germany).

/iMAlIS

Pf/iCfMr.

€

Diagram IV gives the comparative frequency of gall-stones
in males and females in the United States, based on Johns
Hopkins autopsies. The difference in frequency as com-
pared with Germany is seen by comparing this with Diagram
V, which is based on Schroder's eases, as quoted by Naunyn.

TABLE VI.

Freqriencij of GaU-Stones in Males of Different -if/es in 1037 Aiilnpsies,

[Frmn the Pfitlmlngteal Department i>f the Johns Hopfcins Hospital].

. , M„™h=,./>f Number of Percentage of cases

„-?St °i„ „l^^„=Lc cases having e.\amined in which g-all

paiienis. autopsies. g-all-stoncs. stones were present.

0-30 107 ..

21-30 ISO 3 1.11

31-40 202 7 3.46

41-.10 213 13 6.10

.51-60 170 14 8.23

fil and over 162 20 13.28

Age unknown .... 3 .. ....

Totals 1037 .57 5.49

TABLE VII.

Frequency of Gail-Stones in Females of Different Ages in 618 Autopsies,

[From the Pathulnyical Department of the Johns Hopkins Hospital.]

Ap-pnf Niimiipvnf Number of Percentage of cases
naWents auto sfes cases having e.xamined in which gall-
patients, autopsies. . gan^gtones. stones were present.

0-30 125 1 O.S

21-30 97 3 3.06

31-40 131 11 8.39

41-.50 115 10 14.00

51-60 88 30 23.70

61 and over 57 S 14.21

Age unkno\\'n . . . . 5 . . ....

Totals 61S 58 9.37

Apparently the men in the United States have gall-stones
in 5.49 per cent of cases as compared with 4.4 per cent for
the German men, or about one per cent more frequently.
Tables VI and VII give respectively the number of cases of
males and females in the Johns Hopkins autopsies, arranged
according to age groups, the number of cases occurring in
each group, and the frequency of gall-stones for each age in
percentage.

Diagram VI.

Comparative Frequency of Gall-Stones in 1037 Males and 018
Females by Ages (United States).

Females ^^mm,

1-4

vii

/■/

O/i

OIA

256

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 13.^

Diagram VI graphically shows these results. The black
lines represent the frequency for the females in percentage
in each age group, the red lines the frequency I'or tlic males.
Again the females in the group of from 51 to GO years old
reach the maximum frequency of cases having gall-stones,
and there is a falling off in the succeeding group of Gl years
and over. If we refer to Table VII, it will be seen that the
number of cases in the last group is rather smaller than in
the preceding one, while a slighter difference in numbers is
seen in the corresponding group of males. If we compare
the character of the curve for the blacks in Diagram III,
where the whole number of black cases was 634 as compared
with the 1018 white cases, and remember that there are only
618 females as compared with the 1037 males, it will be seen
that the two curves based on the two larger groups of cases
correspond very closely in character, showing an almost uni-
form increase from age group to age group, both reaching
their maximum in the last group. Of the two curves based
on the smaller number of cases, 634 in one, and 618 in the
other, both show the maximum frequency in the age group
of 51 to 60 years. I am at a loss to explain this fact unless
it be due to the smaller number of cases included in this last
group.

Elivlogij: Nauuyn has ascribed the greater frequency of
gall-stones in women to wearing of tight clothing and to preg-
nancy, each of which hinders the flow of the bile. Schroder
found gall-stones in more than half of the cases having a
tight-lace furrow on the liver. Reidel showed that the de-
formity of the liver from this cause disturbed the normal
situation of the liver, especially affecting the gall-bladder,
which is turned downward, the cystic duct being stretched
and the emptying of the gall-bladder made more difficult.
Among the Johns Hopkins cases there was but one (Path.
No. 988) in which this was noted. In this the gall-bladder
had to be placed in a certain position before the fluid bile
could be squeezed through the patent ducts, because there was
a sharp deflection in the cystic duct. Wiesker demonstrated
that the ligamentum hepato-duodenale is stretched in cases of
floating liver or of floating right kidney; this also affects the
cystic duct and hinders the emptying of the gall-bladder.
Litten also pointed out that movable kidneys may cause bil-
iary obstruction. Mignot, Gilbert, I'ournier, Gushing and
others have produced gall-stones experimentally in animals
by the inoculation of attenuated cultures of the bacillus coli
communis or bacillus typhosus. Dr. Gusliing' calls atten-
tion to the necessity of producing the necessary catarrhal
inflammation of the gall-bladder before calculi will form even
when the organisms are present. Naunyn has also stated
the two factors necessary to the formation of gall-stones to
be stasis of the bile and the presence of organisms. Dr.
Welch has also shown by the culture of streptococci as well
as bacillus coli communis and bacillus typhosus that more

■•Cuahing, Harvey: Observations upon the Origin of Gall-Bladder
Infections and upon the Experimental Formation of Gall-Stones, in
Johns Hopldns Bulletin, Vol. IX, pp. 166-170.

forms than the two latter organisms may be concerned in
the formation of gall-stones in the human subject.

Attention has been called to a number of the several fav-
oring conditions wliicli may produce stasis of bile in women.
It may l)e worth wliile to enumerate them briefly once more.

1. cnothing: (a) changing diaphragmatic to the costal type
of respiration and thus the absence of diaphragmatic action
producing a stasis of the bile; for, according to the state-
ments of Naunyn, Heidenhain and his pupils have proved
experimentally that the descent of tlie diaphragm is an im-
portant factor in emptying the gall-bladder; (b) or causing
gross lesions, such as the tight-lace furrow or long liver
lappets, leading to displacements which cause mechanical
obstruction to the outflow of the bile.

2. Lax abdominal walls, whether from inactivity or too fre-
quently repeated pregnancies, and enteroptosis, by which the
emptying of the gall-bladder may be hindered through the
alteration of the relations of the gall-bladder and its ducts.

3. The presence of large abdominal or pelvic tumors, such
as a large myomatous uterus or even in some cases the gravid
uterus, thus producing pressure which may cause stagnation
of the intestinal contents — a favorable condition for the
invasion of the bile passages by the ever-present colon bacillus.

4. The great frequency of puerperal infections of varying
intensity, as well as the numerous cases of pelvic inflamma-
tory disease of other origin, with peritonitis and adhesions,
may certainly furnish a number of eases of mechanical ob-
struction as well as sources of infection. In the male sex
there is no corresponding group of possible sources of me-
chanical obstruction to outflow of the bile which can be
compared with these favoring conditions in the female to
the formation of gall-stones. It would seem probable that
any one of these factors, acting singly, would be sufficient
to explain the greater frequency of gall-stones in women.

Some authors have called attention to the frequency of
gall-stones in the poor and badly nourished, while othei-s
have held that gall-stones occur more frequently in the rich
and overfed classes. In order to determine this question,
the cases from the Bay View Asylum and Almshouse ser-
vice have been separated from the whole body of cases. By
the courtesy of Dr. Opie of the Pathological Department, it
was possible to get the records of 125 cases from the Bay

TABLE VIIT.

Frequency of Gall-Stones in Persons of Different Ages, in 13.5 Autopsies,
[From the Pathological Seri'ice of the Bay Vieif Asylum and Almshouse.]

Number of Percentage of cases

cases having examined in which gall-
gall-stones, stones were present.

Age of
patients.

Number of
autopsies.

0-30

31-30

31-40

41 -.50

51-60

61 years and over .

Totals

135

3
2
3

7.69
12.05
10.
15.
16.

12.8

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

257

View service. Table VIII gives these cases arranged in age
groups, whicli makes it possible to contrast these cases with
exactness.

Of the 125 eases from tlie Almshouse and Asylum 10, or
12.8 per cent, had gall-stones, as compared with the fre-
quency of 6.9-t per cent for all cases considered together.
In other words, gall-stones were present in the Bay View
cases almost twice as frequently as in the 1655 autopsies.

This increased frequency in the Bay View cases is par-
tially but not wholly explained by the greater number of
cases over 30 years of age in Almshouse and Asylum autop-
sies. The numbers are too small to warrant any conclusions
at this time.

In 115 cases of the 1655 autopsies gall-stones were present.
Death was to be attributed to their presence or effect in only
13 cases; in the remaining 102 cases the gall-stones were
merely incidental.

The number of stones present, when specified, varied from
1 to 250 stones. Tlie location of the calculi was as follows:

lu eaU-blatlJer alone iu 81! eases.

" and common duct (1 "

" and cystic duet Ill "

" and hepatic duct 1 "

In gall-bladder and common and cystic duets 2 "

" " common and hepatic ducts 1 "

" " commou, cystic and hepatic ducts 2 "

" " common, cystic, hepatic and the larger

ducts of the liver 1 "

" " common, hepatic and larger ducts of the

liver 1 "

" " larger ducts of the liver 1 "

In common duct alone 1 "

In cystic duct alone ! "

Common and hepatic ducts ] n

Location not specilied. (Stones removed at previous opera-
tion.) 1 11

1 15 eases.

From this classification it will be noted that gall-stones
were present iu the gall-bladdrr in 111 cases. In only i
cases was the gall-bladder free from concretions when their
presence was noted in any other portion of the biliary sys-
tem. Biliary calculi were found in the ductus communis
choledochus in 15 cases; in the cy.stic duct fifteen times; in
the hepatic duct seven times, but always in association with
calculi iu other portions of the biliary system. Biliary cal-
culi were found in the ducts of the liver in two cases. In
the first case (Path. No. 1102) the concretions were only in
the larger ducts of the liver; but in Path. No. 1530 the cal-
culi were present in both the larger and smaller ducts. In
0 cases concretions were present at the papilla or the Diver-
ticulum of Vater.

The condition of the biliary system was as follows:
Gall-bladder condition was noted in 28 cases. The gall-
bladder was distended in 22 cases, not distended in 1, and
reduced in 5 cases. There were adhesions about the gall-

bladder in 14 cases; the peritoneum over the gall-bladder was
thickened in 9 cases. The mucous membrane was thickened
in 10 cases, eroded in 1, and necrotic in 2 cases. One case
showed healed scars, and in 4 cases the mucous membrane
was infected; in 4 cases the mucous membrane was stated to
be normal.

Cirrhosis of the liver was present in 21 cases. There were
liver adhesions in 24 cases. The capsule was thickened in
11 cases. Several small phleboliths were pre.-^eut in one
case. The tight-lace furrow was noted in 4 cases, three
times in women and once in a man.' A long liver lappet
was present in 6 cases.

If we consider the gall-bladder adhesions and the adhe-
sions about the liver, the number of cases in which me-
chanical obstruction to the flow of bile was possible is fairly
frequent.

The condition of the bile was as follows: In 33 cases it
was described as viscid, thick or tenacious, and in 1 case in-
spissated; in 10 it was cloudy or turbid; in 3 cases there was
a granular sediment and in 1 case the bile contained solid
particles. In one case the bile was so tenacious that it could
not be squeezed through flie patent ducts. In 11 cases it
was described as fluid ur lliiii. In 3 cases there was a mucous
jjlug in the moutli of the common duct which had to be
e.xpressed before bile could be squeezed into the intestine.
The above conditions might be grouped under a general head
— eases in which was present mechanical obstruction, which
might interfere with a flow of the bile. (1) Adhesions about
gall-bladder or liver; (2) interference with the free movements
of the diaphragm in respiration, indicated by the presence of
tight-lace furrow on the liver; (3) changes in the bile itself
when its fluidity is lost; (4) mucous plug in luouth of common
duct. ji^j

lafeclions: Twenty-four cases were recorded in which was
made a bacteriological examination of the bile. In 11 cases
the bile was sterile. Bacillus coli communis was found in "i
cases; B. proteus vulgaris once; B. coli communis with the
Diplococcus lanceolatus twice; the streptococcus was found
in one case. Bacteriological examination of llie gall-stones
showed them negative iu three cases. B. coli communis was
present in one case, and a capsulated bacillus in another.
Dr. Welch states that in addition to frequently having cul-
tivated B. coli communis from gall-stones" he has also culti-
vated B. typhosus and the streptococcus.

In the cases where the bile and gall-stones are recorded as
sterile, I understand it to mean that they were sterile as far
as the ordinary pyogenic organisms are concerned, no spe-
cial cultures being made to show the jjossible presence of
the tubercle bacilli or the gonococcus.

In 12 cases there was recorded a previous history of
typhoid fever. In 6 cases no bacteriological examination of

s Welch, William H. : The Bacteriology of Surgical Infections, in
Dennis' tii/sCem of Surgery, Vol. I, p. Sfi.'i.

« Fitz, G. W. : A Study of Types Respiratory Movements, Journal of
Exp. Med. Vol. I, p. GTS.

258

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

stones or bile was made. In one case the bile and stones
were sterile, and in one the stones were sterile. B. coli com-
munis was present in the bile once; B. subtilis was found in
the bile once; and the streptococcus was present once. In
none of the 12 cases was B. typhosus recorded as being pres-
ent.

The pathological conditions found were as follows:

Tuberculosis was noted in 14 cases, or 12.17 per cent.

Aiierio-Sclerosis: Benecke has called attention to the
great frequency of atheromatous degeneration with gall-stones.
According to Naunyn the statistics of Sloth (Erlangeu) and
Schroder (Strasburg) have not strongly supported Benecke's
statements. They found atheroma in about 25 per cent of
their eases. Here there was arterio-sclerosis in 50 eases, or
in 43.48 per cent of the 115 cases in which gall-stones were
present.

Nephritis was the most frequent of all the associated
conditions found. In 69 cases there was definite nephritis
and in 9 additional cases there were lesions of the kidneys
sufficient to interfere more or less with proper functioning,
making a percentage of 72.17.

Uterine myomata were present in 13, or 22.43 per cent, of
the 58 cases in which gall-stones were found in women. In
48 women whose gall-bladders Dr. Kelly explored in the
course of a lower abdominal operation, gall-stones were found
in 7 cases, or 14.5 per cent.' On examining the list it is
found that every case, or 100 per cent, of these cases in
which Dr. Kelly had found gall-stones had been operated
upon for either myoma or large ovarian cyst. While the
number of cases is too small to form any definite conclusions,
this fact suggests a possible association due to pressure.

Carcinoma of gall-bladder occurred in 2 cases. Lumbroi-
coid worms were found in the gall-bladder in 2 cases. Pan-
creatitis was present in one case (Path. No. 1574). Pancrea-
titis with fat necrosis ' was noted in four cases (Path. Nos.
214, 1530, 1567, 1614).

In 22 cases in which no definite concretions existed, there
were abuoi-mal conditions of the bile which suggested the
possibility of a preliminary stage to the formation of gall-
stones. The bile was described as follows: bile contains
granular sediment; sandy particles; friable dark sediment,
soft brown irregular flakes; flocculi, which on examination
prove to be clum[)c(l typlioid bacilli; small masses of blackest
pigment, etc.

Among our 115 cases, floating kidney was noted but once.
In the Johns Hopkins cases, tight-lace furrow was re-
corded but four times, three times in women and once in a
man as has been stated. Fitz has called attention to llie
effect on respiration of the wearing of tight belts by men.
It is conceivable that since the type of respiration in women
may be modified by tight lacing and a similar change pro-
duced in men by the wearing of tight belts, a deformity of

' By au error the percentage frequency of sail-stones was priuteil in
Dr. Kelly's article as 8 per cent when it sliould have read 8 cases.

»Opie, Eiiyeue I..: The relation of C liolelithiasis to Disease of the
Pancreas and to Fat Necrosis, iu Amer. Jonr. of Med. Sci., Jan. IStOl.

the liver produced by tight lacing in women might also be
produced by the wearing of a tight belt by a man. Among
the 58 women having gall-stones, only 3, or 5.17 per cent, bail
the tight-lace furrow; if we include those cases having a
long liver lajipet as jjossibly due to constriction, it amounts
lo only about 19 per cent in which these lesions could
possibly be considered an etiological factor.

Naunyn also states that, apart from these gross lesions,
the bile stream is liable to be hindered by the dress of women
and in pregnancy. He quotes Heidenhain and his pupils
as having proved by experiment that the expulsion of the bile
from the common duct is materially aided by the movements
of the diaphragm.

My own experimental work on respiration has demon-
strated that pregnancy interferes less with the respiration
than has generally been believed. The respiratory move-
ments in the different regions tend to become equalized, but
the diaphragmatic respiration persists as late as the eighth
and even the beginning of the ninth month of pregnancy.
My experiments clearly demonstrate that clothing is the most
potent factor in the production of costal type of respiration
in many women.

It has been seen that myomata have been found in 22.43
per cent of the 58 women having gall-stones, and Dr. Kelly
in operative cases has found gall-stones in 14.5 per cent of
(he cases where the gall-bladder was explored in the course
of a lower abdominal operation; 100 per cent of his cases in
which the gall-stones were present were operated on for
myoma or large ovarian cyst. If the gravid uterus is an
etiological factor in the fonnation of gall-stones, should we
not rather look to the pressure effects as shown by any pelvic
or abdominal tumor, as favoring such formation by pro-
ducing constipation, than to the action on tlie diaphragm as
tlie mode of action?

Conclusions: Pending the study of other series of cases
from various parts of the United States, we may draw the
following conclusions:

Nationality: On the basis on the analysis of the 1655
autopsies from the Johns Hopkins Pathological Department,
as compared with 1150 (?) cases as given by Schroder of
Strassburg, gall-stones are less frequent in the United States
than in Germany, the United States showing a frequency of
6.94 per cent, Germany of 12 per cent.

Age: The frequency of gall-stones in a given number ol'
cases will increase with the age of the patients examined.
The American cases tend to confirm the statements of pre-
vious observers that gall-stones are rare before the thirtieth
year and more frequent after that age.

Color: Gall-stones are more frequent in the white than
iu the black race, the American cases showing a frequency of
7.85 per cent in the whites and 5.51 per cent in the negro.

Sex: Women are more liable to have gall-stones than are
men, the American cases showing the frequency in 618
women to be 9.37 per cent, and in 1037 men to be 5.94 per
cent. The Atnerican women liave gall-stones only about
half as frequently as the German women. In the United

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

259

States only about cue woman in every 10 has biliary calculi,
while ill ClLTiiiaiiy, according to Naunyu, gall-stones are
I'ounil ill 30.6 jaer cent, or in about one woman in every 5.

Discussion.
Dr. Kelly: I am sure all have listened with much satis-
faction to this well prepared and interesting paper by Dr.
Moshcr. It is particularly satisfactory to me that we send out
from this Society the first elaborate statistics compiled on
this subject in America. The immediate occasion of Dr.
ilosher's investigation was that I have recently, whenever

making a large enough abdominal incision, made an explora-
tion of all the abdominal organs, and in these cases I have
found about 14.5 per cent of gall-stones with more or less ex-
tensive pathological changes. In each instance I removed
the stones by a simple and rapid operation by pushing the
stone up against tlie abdominal wall from within, while cut-
ting down from the outside on the hard body; I then everted
the gall-bladder, incised it, and the stones were popped out.
It then became a matter of interest to know just how fre-
quently gall-stones were found, and Dr. Mnshcr has taken up
the work and has made a wide and thorough investigation.

TENDON TRANSPLANTATION/

By Sydney M. Cone, M. D.

Fertile fields in physiology have been opened up before
now through ■\\ork done in the pathological laboratory.
How much did the degeneration of nerve tracts aid in working
out the anatomy of the cord?

There is no present knowledge of the limit to which the
questions brought up and answered in the recent work on
tendon transplantation will lead. Some very interesting
physiological as well as surgical facts are before us.

Nicoladoni, in 1881, successfully changed the position of
some active tendons in a paralytic club-foot to take the
place of the paralyzed muscles. In the three cases reported
he improved the mechanism of the feet very greatly. It
seems that the operation should at once have taken a finn
position in surgery.

It was not until Goldthwait published his cases in 1896
that the subject was again brought before us. Since then
in Germany, France and the United States a number of
orthopedic surgeons have demonstrated the great value of
tendon transference. Its position in surgery is assured, not
only because of the great usefulness of the procedure, but
also because of the absolute safety and exact surgery of the
operation. It is used in various conditions. Goldthwait,
Bradford, Vulpius and Hoffa "have described fully the method
of application for deformed feet following infantile paralysis.
Eulenberg, Hoffa and Vulpius wrote of its application to the
cure of the spastic condition in Little's disease. Eochet,
Townsend, Franke, Drobnik, Vulpius and others described
the use of tendon anastomosis in musculo-spiral paralysis.
Goldthwait, Vulpius and Milliken carried the active sartorius
over into the fascia of the quadriceps femoris. Hoflfa united
the deltoid to the paralyzed triceps.

Vulpius and Hoffa both claim the usefulness of this oi)era-
tion in cases of muscular dystrophj'. Eulenberg and Hoffa
suggest the advisability of using implantation in case of
apoplexy paralyses. It has been used successfully after trau-
matic paralysis or where muscles were congenitally absent.

' Read before the one hundred and third Annual Meeting of the Mary-
land Medical and Chirurgical Faculty, April 35, 1901.

Kuuik, in naming the operations according to how the
tendons are united gives four forms. He adds to the " active,"
" passive " and " active-passive " forms of Hoffa a method
used by Goldthwait — transplanting the periosteal insertion
of the tendon to another place on the bone. Goldthwait
used this in relaxation of the patellar ligament with disloca-
tion of the bone. As a i-ule, Lange, of Munich, uses the
periosteal method. He adds to the technique an original
and interesting method of lengthening the tendons which
he desires to transplant. If in carrying the biceps and semi-
tendinosis around the femur to take the place of the quadri-
ceps, he finds these united tendons too short, he supplies the
deficiency with silk, which he sews to the periosteum at the
tubercle of the tibia. Not only do these two posterior
muscles take the place of the anterior paralyzed one, but the
tissue thickens about the silk and makes a permanent attach-
ment. The other three methods are named differently by
various operators.

Hoffa refers to the rmion of a divided sound tendon into a
paralyzed one as "active"; Vulpius calls this a "descending"
transplantation, while Kunik uses the expression " intrapara-
lytic implantation." When the divided distal end of a para-
lyzed tendon is carried to the sound, undivided tendon, Hoffa
uses the term " passive," Vulpius names this " ascending "
transplantation, while Kunik calls it " intrafunctional im-
plantation." Where both are divided and united both names
are combined, a hyphen separating them, e. g. " active-
passive."

Having determined that the operation is necessary, the
method to pursue is, as a rule, determined simply by the
anatomy of the part involved. Hoffa gives a schedule of
various paralyses, their accompanying deformities, and sug-
gests the method of transplantation suitalile for the case in
hand.

It is conceivable in some instances that owing to changed
anatomical conditions, other methods of effectual tendon
transference might be adopted. Goldthwait demonstrates
this in the pictures he shows of the unusual action of the

260

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

pcronei muscles when, after long paralysis of the posterior
group of leg muscles, they are carried forward in front of
the malleolus. Again, in case of the sartorius, the action
differs according to the amount of padding forming the
fulcrum for it to act upon. It is not difficult to abstract the
best from wliat has been written on this subject up to the
present time.

Before deciding to operate, the patient must have had
every possible chance for the relief of the defonnity. Mas-
sage, electricity, active and passive movements are usually
recommended for one or two yeai's before advising operative
measures. If immobility prevents the limb being placed in
a good position, " redressement " must precede the operation.

A thorough electrical and physical examination must be
made. One cannot always depend upon the intelligence of
the patient in determining what muscles are intact. It may
even be necessary to await the first incision before we learn
the condition of the muscles. The normal muscle is dark
red, the paretic muscle is rose red, while the completely
])aralyzed muscle is yellow. Wliile the method of imiting
the tendons differs, it is generally conceded that the least
possible traumatism to sheath and tendon is required. The
broadest union one can get and a freshly serrated surface
arc desirable. Silk is generally conceded to be the best suture
material. Quilted sutures are preferred as a rule.

The first dressing is done in nine days, but the limb must
remain in plaster for about five weeks, after wliich massage
and pa-ssive action may be adopted.

It is usually noted that the new arrangement works ;\ell
at the first dressing.

There are few variations in the method of treating the
same paralytic condition. In musculo-spiral paralyses.
Rochet. I'ranke. YTiljiius. Drnlmik and Townsend have liad
the greatest experience. They agree tliat it is usually neces-
sary to shorten one or more of the extensor tendons, trans-
planting a flexor muscle at the same time. The flexor muscle
most commonly recommended to be used is the flexor
carpi idnaris. Townsend advises carrying it between the
radius and ulna, while other operators prefer to wind it
around the wrist. The operations upon the foot present few
alternatives as seen from Hoffa's schema.

AVIien the newly transplanted muscle takes on its new
work shortly after the tenth day one is led to question how
this is to be explained. How is it that a flexor extends?
How explain that a muscle accustomed to act through being
stimulated by a nerve lookekd upon as governing one kind
of motion, now changes its way of acting under the same
nerve influence? It would seem that the changed condition
of things in the periphery causes a changed central (brain)
arrangement. The nerves have no specific action, they are
merely the connecting links between muscle and brain.

Lange made a most interesting observation in cases IV
and V of his series, where he split the tibialis anticus tendon
and attached one portion to the cuboid bone. This muscle
learned to perform two separate movements — inward and
outward rotation of the foot. If one and the same muscle

can be thus doubly educated, it should not seem strange that
when relieved of all its original duties it could accommodate
itself to a new simple brain-muscle relationship.

It is due to a rapid re-education of the transplanted muscle,
which is more apt to take place in youtli " before the fre-
quently practiced coordinated actions, especially those asso-
ciated with position, have become fixedly automatic "
(Eulenberg).

Drobnik says that the nerve centres accommodate them-
selves properly within certain bounds to the changed group-
ing of the muscles.

Eulenberg says " It is not only possible, but in the highest
degree probable, that excitations are set up in a centripetal
manner in the cortical portion of the brain which regulates
coordination. These can connect themselves with regulating
impulses starting in the cortex, which impulses were meant
for other work and purposes. These central apparatuses,
commanding and regulating the coordinating mechanism,
must possess a much greater adaptability in young children
than in adults, in whom the more important and oft-exercised
coordinated actions, especially those associated with place,
have become fixed in firmly arranged automatic actions.
The artificial peripheral switching off of the centrifugal
innervation into other antagonistic muscles for purposes of
divided function or transferred function must cause changes
in the centripetal impressions and reactions. Probably this
change will shut off tracks already present and form new
routes. Thus we would get a new regulation of the whole
innervation founded on the new frmctional needs."

This will explain any of the problems in this much-
discussed field. It even touches the question one must ask
when, in a case like the one I shall describe, following correc-
tion of the deformity of tlie foot the paralyzed tliigh mus-
cles recovered their activity. It would seem that having a
group of muscles which have been educated together, several
of them being lost, the rest do not get the centrifugal stimuli
they formerly got because the centripetal stimuli were want-
ing. Now, when the old centres in the brain are again
stirred up by centripetal stimuli, after the operation on a
few of the paralyzed muscles which were accustomed to start
the motion in the coordinated movement, all get the cen-
trifugal stimulus thus set up.

The case to be reported is that of a girl (K. S.), 7 years
old, admitted to the Robert Garrett Hospital, Jan. 9, 1901.

She had been lame for four years, dragging the left limb
in an everted position. The foot was in the position cavus
and had little support at the ankle joint. It was slightly
pronated. Very little information conkl be obtained from
the mother al)Out the origin of the paralysis. It came on
suddenly while the child was in good health. The child be-
gan to limp, the leg wasted, and the skin took on the ap-
pearance of ■' goose skin."

Examination showed the left limlj to be from 2-5 cm.
smaller than the right one. Electrical and physical examina-
tion showed paralysis of the tibialis anticus, gatrocnemius.
soleus, tibialis posticus and flexor longus pollicis. She could

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

261

not invert the limb at all, whether from paralysis of the
semimembranosis and tendinosis glutens medins or tensor
vagina femoris, or to all, I conld not determine. No elec-
trical response was noted in any of these ninscles.

On Jan. 23, under ether, an incision was made 8 cm. long
across the tendo Achilles. The peroneus longiis and brevis
were exposed and cut across near their insertions. The
[leroueiis brevis was carried under the tendo Achilles and
through an opening in the flexor longus pollicis. The
jjeroneus longus was serrated and passed through a slit in the
width of the tendo Acliilles. liuilted sutures were used to
llx them as described by Goldthwait. A silver wire sub-
cutaneous suture closed the wound. In ten days (Feb. 1) the
first dressing was made, showing union per primam. The
r-liild was kept in plaster for three weeks, then given massage
and passive movements. She soon began to walk without a
])laster dressing. It was noted at once that she turned the
foot in, although there remained a tendency to outward
rotation when she did not try to hold her limb in the correct
position. To correct the supination and laxity of the support
on the inside of the foot, I did the second operation on
April 5. The opportunity to do these operations was afforded
me throngli the kindness of Dr. Piatt.

An incision G cm. long was made above the annular liga-
ment, exposing the tibialis antieus and extensor longus
iligitorum. A section of the tibialis was carried through an
opening made in the extensor longus digitoruin and lield
there with cjuilted sutures.

The skin suture was silver wire. The first dressing was
done in eight days. The wound had healed per primam, and
the contraction of the extensor longus digitorum drew the
foot in and up. The patient left the hospital in four weeks
with the foot in plaster. The child is now at home, being
treated with massage, passive and active exercise. She has
perfect plantar flexion and improved use of her dorsal foot
muscles, and will doubtless continue to increase the activity
of her newly acquired movements.

Bibliography.

Bradford. — Tenoplastic Surgery. Annals of Surgery, Aug.,
1897.

Drobnik.— Deutsch. Zt. f. Chir., V. 43, 1896.

Eulenberg. — Zur Therapie der Kinder lahmungen. Sehneu-
liberpflanzung ir einem. Falle Spastischer Cerebraler Para-
plegic (Sog. Littlescher Krankheit). Deutsch. med. Wochen-
schr., April 7, 1898.

Franke. — Ueber die Operative Behandlung der Radialis-
liihmung nebst Bemerknngen iiber die Sehnentiberpflanzung
Ix-i spastischcn Liihmungen. Arch. f. klin. Chir., Bd. 57,

nt. 4.

Goldtliwait. — Tendon Transplantation in the Treatment of
Paralytic Deformities. The Boston Med. and Surg. Jour..
Jan. 9, 1896.

The Direct Transplantation of Muscles in the

Treatnu'ut of Paralytic Deformities. Trans, of the Am.
Orth. Ass., 1897.

Permanent Dislocation of the Patella, etc. An-
nals of Surgery, Jan., 1899.

Gocht. — Bcitrag zur Lchrc von der Schuenplastik. Zeit.
f. Orth. Chir., Bd. VII, Ut. 1.

Hofia. — Zur Lehre Vdu der Sehnenplasfik. Berl. klin.
Woch., July 24, 1899.

Lange, Fritz. — Ueber periostalo Seliuenverpflanzungen bei
Liihmungen. Munch, med. Woch., April 10, 1900.

Ivunik. — Ueber die Funktionserfolge der Selmeniiber-
pflanzungen bei paralytischen Deformitilten insbesondere
nach der Spinalen Kiuderlahmung. Munch, med. Woch.,
Feb. 12, 1901.

Nicoladoni. — Nachtrag znm Pes Calcaneus und zur Trans-
plantation der Peronealsehuen. Arch. f. klin. Chir., No. 27,
1882.

Eochet. — Des Anastomoses tendineuses entre Muscles
saines et muscles paralj'ses pour la coiTection des deviations
on de deformites paralytiques. Lyon Med., 1897, No. 34.

Townsend, W. E. — Tendon Transplantation in the Treat-
ment of Deformities of the Hand. Trans, of the Am. Orth.
Ass., Vol. XIII, 1900.

Vulpius. — Die Selmeniiberpflanzung bei Lahmungen und
Liihmnngs deformitiiten am Fuss imd insbesondere an der
Hand. Berl. klin. Woch., No. 37, 1898.

PROCEEDINGS OF SOCIETIES.

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Fehruarij IS, 1901.

In the absence of the president, the meeting was called to
order by Dr. Osier.

Chorea witii Eiiibolisiii of Central Retinal Artery. Dn.
Thomas. Ophthalmoscopic Appearances. Dk. Reik.

(To apj)ear in a future number.)

Volvnliis of Meckel's Diverticnliim with Recovery after Opera
tion. Dk. William .J. Taylor, of Philaiklpliia.

(To appear in October Bulletin.)

Monday, March J,, 1901.
In the absence of the president, the meeting was called to
order by Dr. Kelly.

Exhibition of Medical Cases. Du. INIcCkaf..

The cases I will show this evening are cases of severe
ansEmia that might well be called pernicious auismia. They

262

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

are now to be shown, however, on aceonnt of some associated
symptoms.

Tlie younger is aged 38 and came, in complaining of stiti'-
ness in the arms and legs with some numbness. His present
illness dates back to the summer of 1898, when he was some-
what " run down."' He continued to work until March, 1900,
when he was compelled to stop on account of shortness of
))reath and weakness. In the January previous he had a
carlnincle of the neck which presented nine openings. He
has a curious waxy, yellow color, is very weak and has some-
times sliortness of breath.

I would like first to call attention to a symptom that may
have some bearing on the cause of pernicious ana?mia. You
are probably all familiar with the recent writings of Dr.
William Hunter, who has suggested that pernicious anaemia
is often due to foci of suppuration, sometimes even so simple
as a carious tooth. On exannnation we found this patient's
teeth exceedingly bad, and he tells me that has l)een his con-
dition for five years past.

His blood shows no special features beyond a Inrmoglobin
estimate of 50;?;, a red count of 2,500,000, and leucocytes
2000, with 45;^ of mononuclears and an occasional nucleated
red cell. Coming to the sensory symptoms of which he
complains, namely, numbness and tingling, we have not made
out anything peculiar on examination about sensation which
appears to be normal. His knee-jerks are exaggerated.

The other case, a patient of r^8, has Ijeen in the hospital
since the 8th of October. He complained of numbness of
the limbs aiul ]iain along the spine, his symptoms dating back
for a period of 18 months. His first symptom was weakness.
He fell down stairs one day and after that was unable to
work for some time. His blood on admission showed
1,900,000 red cells, a hai'moglobin of 48;^, and 48;^ of mono-
nuclears. On admission he showed a curious tottering gait
and was almost unable to walk unsupported. He had no
Romberg sign and the knee-jerks were somewhat exaggerated.
He has imjiroved very much, but still walks with some hesita-
tion and holds himself stiffly. The knee-jerk has gradually
diminished until now it is only elicited with some difficulty.
His luvnidglobin went up to TO^ and the red corpuscles to
3,.500,000 per cmm.

The whole group of spinal symptoms in connection with
antemia is extremely interesting, although as yet the subject
is in a rather chaotic state. One can separate undoubtedly
a group of cases of which this man is a type that are associated
without doubt with pernicious anemia. A number of cases
have been reported from the National Hospital for Nervous
Diseases in London that occurred after anaMuias that are
evidently secondary anannias.

In amemias, three types have been described: one where
the anajniia is primary, a second where the cord changes are
primary and ana^nua develops later, and a third where with
ana?mia there are no symptoms of spinal cord involvement
during life, but it is found on section. The coincidence of
these two cases is interesting.

In regard to the question of treatment, I think this young

man should undoubtedly have his mouth carefully attended
to, the carious teeth drawn and the mouth cavity cleaned up
as well as possible. In addition to that, he is getting arsenic
and good feeding. The outlook is difficult to determine. In
the other case, judging from the cases reported, the progress
is probably downwards. Three stages of that have been
described: First, a spastic condition; second, the condition in
which he is now; and thirdly, a perfectly flaccid paralysis
that usually ends fatally. He has been having the ordinary
treatment of good food, arsenic and fresh air. In the last
two or three weeks he has lost nearly a million red blood-
corpuscles, but there is no increase in the s]iinal-cord symp-
toms in connection with that drop.

Discussion.

Dr. Tii.vyee. — Within the last two years I have seen two
very interesting cases of pernicious ana?mia with symptoms
of involvement of the cord. In the first instance, seen last
year with Dr. Watson, the patient developed a very high
degree of ataxia of both lower and upper extremities and
loss of reflexes. There was incontinence of urine and faeces.

The second case I saw about two weeks ago with Dr. Beck.
The first symptoms of her anaemia began during the heated
term last sum hut. During the fall she began to have diffi-
culty in using her fingers and her hands became weak. There
was considerable numlmess and tingling. She was nnalile
to button her clothes. Shortly afterwards she began to have
the same sensations in her feet and noticed a certain unsteadi-
ness of gait. On several occasions she fell. When seen the
patient showed a high degree of ana?mia, only about ].r)00,000
red corpuscles; there was no marked atrophy in the upper
extrenuties, but great weakness of the muscles in tlie arms
and hands. A distinct increase of the reflexes at the elbows
and wrists. There was fairly well-marked ataxia, especially
of the right hand, the patient being unable to tiubutton her
clothes. There was no atrophy in the legs or thighs, no
fibrillary trenuir; knee-jerks diminished but still present. On
superficial exauiination sensation to touch and pain was
normal tliroughout. The ]iatient distinguished the head and
point of a pin well in both arms and legs.

Willi regard to the question of treatment of jiernicious
anannia. it is interesting to note that Dr. Cabot, who has
seen a large number of cases, is of the impression that arsenic
is of little or no value. He states that rest, fresh air and
judicious feeding are the most important iioints in treatment.
I must say that this statement has seemed to me rather sur-
prising. The observation of the cases which have occurred
during the last eleven years in Dr. Osier's clinic has led us to
believe that the drug is of value in many instances.

Dr. Futcher. — I would like to say simply a word or two
in regard to the suggestion of Hunter that pernicious auaunia
may be due to the condition of the teeth. AVhen one reads
his article one is not very thoroughly convinced that his
cases were really due to the involvement of the teeth. His
view is that as a result of the caries of the teeth, Toxic sub-
stances are formed by the bacteria present, which ,on being

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

263

absorbed iuto the blood cause a destruction of the red blood-
corj)iisck'S. He holds that the gastritis so frequently present
is very often secondary to the suiijjurating teeth. He re-
ported nine cases in his original paper, and in all probability
there is some connection between the two conditions, but his
observations require further support before being accepted.
I think in this ease, as Dr. McCrea suggests, it would be
inijiortant to have the teeth attended to.

Coutribtitioii to the Study of the Frcqueiioy of (liall Stones in
the United States. Dr. Moshkr.

(See page 253.)

Diabetes Mellitus Associated nith Hyaline Ueg^cneration of
the Islands of Laugerhans of the Pancreas. Dn. Opik.

The pancreas, it is well known, closely resembles the
salivary glands. The larger dncts are lined with high col-
umnar epithelium which becomes lower and cubical in the
smaller branches while the terminal ducts arc formed by flat
epitlielial cells. The secreting acini arc composed of high,
characteristically glandular cells. Scattered throughout the
organ and distinguishing it from other glands are the peculiar
bodies first described by Langerlians in 1S()11. These consist
of small polygonal, non-granular cells, wliicli ditVer markedly
from the ordinary secreting cells and are not arranged aljout
a central lumen. When the blood-vessels of the pancreas are
injected, corresponding to these groups of cells are seen
glomeruli of dilated and tortuous anastomosing capillaries.
The cells of the island form small solid columns which lie in
the meshes of this capillary network. These bodies are not
penetrated by the ducts and they are entirely independent of
the secreting apparatus. In architecture they resemble cer-
tain ductless glands, the coccygeal and the carotid glands, the
parathyroid bodies and less closely the pituitary gland, the
adrenals and the thyroid. Their structure suggests that they
exert some influence on the blood and are independent of
the external secretion of the acini.

Experimental work has conclusively demonstrated that the
pancreas bears an intimate relation to carbohj'drate meta-
bolism. AVhen the organ is extirpated, sugar accumulates in
the blood and is excreted by the kidneys. The association of
lesions of the pancreas with diabetes has long been known,
and in view of the experimental results a variety of destruc-
tive lesions of the gland may be regarded as the cause of the
disease. Chronic interstitial pancreatitis is the most common
of such lesions. Diabetes, however, does not always accom-
pany chronic pancreatitis.

In a recent number of the Journal of Experimental Medi-
cine I have described two types of chronic pancreatitis. With
one variety, which may be designated interlobular, the in-
crease of interstitial tissue is between the lobules and invades
them from the periphery. In the second variety the inter-
acinar, the new growth of tissue is more diffuse and pene-
trates between the acini. In the first the islands of Langer-
hans are affected by the lesion only when it has reached a
very advanced grade. To this type belongs the chronic

inflammation which follows occlusion of the pancreatic duct.
It the duct be obstructed by calculi or carcinoma the secret-
ing acini are destroyed and replaced liy fibrous tissue, Init the
islands of Laugerhans remain unaffected until the sclerotic
process is far advanced.

Of eleven cases of interlobular pancreatitis, in only one
was diabetes present, and here the chronic inflammation
which followed occlusion of the duct was so far advanced
that the organ was almost entirely replaced by dense scar-
like tissue in which the jiersisting islands of Laugerhans had
undergone alterati(ms. Diabetes had been of very mild
severity, and sugar had disappeared from the urine when the
patient was put ujion a diet poor in carbohydrates. Of
three cases of interacinar pancreatitis, in two diabetes was
present, while in the third the lesion of the gland was very
slight and the organ was of large size, weighing 1 70 grammes.
Where diabetes accompanied chronic interstitial pancreatitis,
the islands of Langerhans were implicated in the inflamma-
tory change; diabetes did not accompany those lesions which
spared tlie islands.

In the same report I described a case of diabetes in which
the jiancreas was the seat of a very remarkable change.
Throughout the gland were sharply circumscril)ed areas in
which between the capillary wall and the parenchymatous
cells hyaline material had been found. These areas in many
instances corresponded in shape and size to islands of Langer-
hans, and nowhere in the gland were these bodies still recog-
nizable. Not infrequently, however, the areas of hyaline
degeneration were much larger and evidently represented in
part at least secreting parenchyma.

In a case of diabetes which has recently come to autopsy,
the pancrea.s was the seat of a similar hyaline change limited
to the islands of Langerhans. This condition occurred in a
negress, 55 years of age, who for eleven months before admis-
sion to the Hospital had suffered with severe cough. Several
months after the onset of her illness she noticed that her
urine had become pale and was very abundant, so that at
night she was compelled to void it every hour. There were
great hunger and thirst. These symptoms lasted during a
part of the spring and summer, but disappeared several
months before her entrance into the hospital. On admission,
physical examination showed the signs of partial consolida-
tion of both lungs and of cavities in both apices. In the
sputum were numerous tubercle bacilli. The urine contained
a large quantity of sugar (4 to 5.4^), although for several
months she had had no .symptoms indicative of diabetes.
She died on the seventh day after admission; death was not
preceded by coma.

At autopsy the lungs were found to be studded with
tubercles, the upper lobes were consolidated, and at both
apices were large cavities. Small tuberculous ulcers were
. present in the intestine. There were no other noteworthy
lesions in the body. The pancreas was of normal size, weigh-
ing 80 grammes, and was of the usual color and consistency.
Microscopic examination, however, demonstrated a lesion even
more remarkalde than that of the previously mentioned case.

264

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

In varying amount within almost every island of Langerhans
was a homogeneous hyaline material replacing the epithelial
cells. It stained deeply by acid dyes, eosin and picric acid.
and in sections treated by Mallory's method for the demon-
stration of fibrous tissue and reticulum assumed a very con-
spicuous deeji blue color; the reactions of amyloid were not
obtained. The smallest particles of this substance were poly-
gonal in shape and cori'esponded in size to tlie cells of the
island. Transitions between the granular nucleated cells and
these homogeneous hyaline particles were found. Where the
process was more advanced the cells of the island were in
gTcat part or wholly transformed, and there occurred small,
round or oval masses of hyaline material penetrated by the
remains of capillaries whose endothelial cells finally disappear.
The secreting parenchyma was unaffected by the lesion
described.

In none of the cases which I had previously described was
a lesion of the pancreas limiled to one or other element of
the gland. Where diabetes accompanied a lesion of the
islands of Langerhans the secreting parenchyma was also
implicated. Where diabetes was absent, the islands persist-
ing unaltered though the secreting parenchyma was in large
part destroyed, a considerable proportion of the glandular
substance still remained intact. In the present case, how-
ever, diabetes followed a lesion affecting only the islands of
Langerhans. It furnishes, I believe, conclusive demonstra-
tion of tlie inferences drawn from the preceding series of
cases. Diabetes mellitus when the result of a lesion of the
pancreas is caused by destruction of the islands of Langer-
hans and occurs only when these bodies are in part or wholly
destroyed.

Discussion.

De. Fdtcher. — I would like to emphasize the great im-
portance of this observation of Dr. Opie's. It is one of the
most important on the pathology of diabetes mellitiTS that
has been made in several years. For a good while the pan-
creas was supposed to be closely connected in some way with
the proper metabolism of carbo-hydrates in the system. In
experimental work it was shown that ligature of the pan-
creatic duct preventing the outflow of the pancreatic secre-
tion into the intestine did not lead to diabetes. It was in-
ferred that there was some internal secretion produced by
the pancreas which reached the general circulation without
entering the intestinal tract. A number of years ago Lepine
advanced the theory that this internal secretion probably
contained a ferment to which he gave the name glycolitic
ferment. He believes that it has the function of causing the
proper combustion of the carbo-hydrates and preventing their
appearance in the urine. It is possible that these islands of
Langerhans are connected in some way with the production
of this ferment, if such a ferment exist. It is at least a very
suggestive idea, and it seems quite conclusive from Dr. Opie's
researches that the inferences drawn from his earlier work in
this line were quite correct.

Carcinoma of the Male Breast. Mr Wakfield.

(To appear in a future number.)

March IS, 1901.

The meeting was called to order by the president, Dr.
A¥elch.

A furious Form of I'eritoueal Tuberculosis. Dk. MacCai.lum.

(To a])pear in a future numl)er.)

A Lipo-Myoma of llie Uterus, with Exliibitiou of Specimen.

Dk. Knox.

(To appear in a future number.)

The Advances Made in Medical and Surgical Diag'uosis by the
Roentgen Metliod. I)i?. Chari.ks Lestkk Leonahd, of

l'hila(lcl|iliin.

(To appear in a future number.)

Monday, April 1, 1901.

The meeting was called to order by the president. Dr.
Welch.

Exhibition of Medical Cases. On Ilemorrhag-e in Clironic
Jaundice. iJu. Oslkk.

An interesting fact in connection with diseases of the liver,
associated with jaundice, is the tendency to hemorrhage. In
cirrhosis of the liver, even with verjf slight jaundice, there
may be frequent bleedings, especially to epistaxis, of which
we have a case in ward now. In chronic jaundice there is a
marked retardation of the blood coagulation time, sometimes
even to 15 or 20 minutes, and with it there is a liability to
spontaneous hemorrhages and a tendency to bleed from
wounds, more particularly those of operation. Surgeons
have this very painfully impressed upon them in recurring,
obstinate, and even lethal hemorrhage following gall-stone
operations. AVe have had lately four cases in the ward with
jaundice and severe hemorrhages.

Case 1. Carcinoma of liver and gall-bladder. Mrs. K.
had suffered with jaundice, accompanied by a great deal of
pain for four months. The blood coagulation time on admis-
sion was ten minutes. A deep-seated tumor-mass of doubtful
character was felt in the region of the liver. The extreme
persistence of the jaundice and severity of the pain made us
suspect malignant disease. On January 27 she had some
slight bleeding from the gums and there was a small quantity
of blood in the stools. On the 28th she bled a great deal
more and was in such a desperate condition that it was
thought advisable to perform a laparotomy. This was done
on the following day and a carcinoma of the gall-bladder was
removed. That night a severe hemorrhage occurred and
persisted till death.

Case 2. You may remember that a few weeks ago I
showed a remarkable case of multiple xanthelasma la and that

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

265

I referred to a second case in the house at the time but too
ill to be brought down. She is now before you and illustrates
in a remarkable way the feature of which I am speaking.
The jaundice has existed for ten years, arising originally, in
all probability, from gall-stones. The point of special inter-
est is that she has had four attacks of hemorrhage of a very
severe character, the last occurring February 18, the day
before admission. For ioin days she had been bleeding from
the nose and uterus, and at time of entrance was almost
bloodless; coagulation time 14 minutes. She has steadily
improved while here, the red cells having reached normal
and the coagulation time has fallen to four minutes. She
has gained weight at the rate of 2 pounds a week, and says
she has not been so robust for some years past. The jaundice
has lessened.

Case 3. Mrs. F. came in recently with a jaundice of 14
months' duration and evidences of gall-stones in the common
duct. She had never had hemorrhages. Blood coagulation
time was 8 minutes, but it fell gradually to 3^ minutes and
she was transferred to the surgeons and operated upon March
5. Numerous gall-stones were found in the common duct
and in the gall-bladder. The day after operation there was
a small hematoma in the region of the incision, and iowr
days later she nearly bled to death. She recovered from the
collapse, however, and has since done well.

Case 4. This patient was admitted in February with
jaundice, nausea and a great deal of pain; coagulation time
3^ minutes. She was transferred to the surgical side on
March 8. On the day following, she had a very severe pain
in the abdomen, which was followed the next day by a
sudden collapse and death in a few hours. Subsequent
examination showed a most extensive hemorrhage into the
lesser peritoneum, the stomach and the tail of the pancreas.
She had gall-stones and cancer of the gall-bladder and liver.

These cases illustrate the liability to hemorrhage in chronic
jaundice and the risk in connection with operation. They
show also the possibility of reducing the blood coagulation
time to normal by treatment. Professor Wright, of Nottey,
has shown that the coagulability of the blood could be in-
creased by calcium chloride. Subcutaneous injections of
gelatin have the same effect, and wc use these measures in
cases of jaundice before transferring them to the surgical side.

Typlioid Spine. Dn. Osleh.

This patient illustrates a very remarkable and unusual
condition, which sometimes puzzles the physician. It is
among the rarer sequels of typhoid fever. The condition
was described by Gibney, of New York, as typhoid spine, and
you will find in our Studies on Typhoid Fever an interesting
series of cases. The condition follows usually a protracted
attack, as in this case, which was admitted Nov. 6 and dis-
charged Jan. 13, after a long and severe illness. He was a
little nervous before leaving the hosjTital, but made a good
recovery, which is the usual history. A month or six weeks
subsequent to convalescence the patient begins to complain

of pain in the back, with stiffness, and finally develops a
complete picture, as you see it here.

The patient is a robust, healthy looking fellow, of fairly
good color, but you can see that he is nervoTis and appre-
hensive. He was brought into the hospital supported by two
friends, and it was with the greatest difliculty that he coidd
be induced to sit down or lie down. Any movement of the
back was excessively painful, and he winced on pressure.
After he was put to bed, and had the thermo-cautery and
the wet packs, he improved with great rapidity, and was soon
able to be up and about. He is still very nervous, and he
has still slight stiffness and tenderness of the spine. These
cases all present a singularly uniform picture; first, a condi-
tion of neurasthenia, often of a very marked degree; some
cases become very hysterical. Secondly, stiffness of the back,
so that attempts to turn or to stoop are very painful. I have
known a patient to remain in bed for six weeks or more,
unable to sit up or move about without agonizing pain.
Thirdly, pain on pressure is usually elicited in the lower part
of the back, sometimes, as in this patient, more to one side
than the other, and at times directly over the sacro-iliac
synchondroses. Fourthly, and this is an all-important point,
tlie local examination is negative, there is no sign of swelling,
no fever as a rule and no leueocytosis. And lastly, the
patients get promptly well, or improve with great rapidity,
with the iise of the Pa<juelin and measures directed to tlieir
neurasthenic condition. It is true it sometimes takes weeks
or months before a complete cure is effected.

The condition has been termed a post-tyi)hoid spondylitis,
and it is possible that in some cases there may be actual
inflammation, but whatever the nature of the malady, and I
must confess it is extremely obscure, I do not think there is
a bone lesion similar to that which occurs so frequently after
typhoid fever, and which almost invariably proceeds to sup-
puration. I have not met with an instance, nor do I know
of one in the literature, in which suppuration has followed in
any part of the spine. I have always regarded the coiulilion
rather as a neurosis, and I must say that it responds to 1lie
treatment which we emiiloy in this class of cases.

Intestinal I))'str.vi)siii (Classification ami Pathogenesis). Dr.
J. C. IIkmmktkk.

Foetal Trnnsniissiou of Typhoid Fever. Dk. Lynch.

Abscess in the Abdominal Wall. lleport of Cases. Dk.

IIUNNKK.

BfOTES ON IVEW BOOKS.

Uterine Fibromyomata, tlieir Pathology, Diagnosis and Treat-
ment. With 49 illustrations. By E. Stanmore Bishop, F. R.
C. S., Eug. (Philadelphia: P. Blaki^ton's Son S Co.)

Although the subject of uterine myomata has always been
one to which the gynecologist and general surgeon have given
much attention, the literature bearing on them being very ex-
tensive, this work of Bishop's is the first extensive book to ap-

266

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

pear in English, devoted entii'ely to the consideration of these
tumors. It comprises some 300 jiages, dealinff with their histo-
genesis, symptomatology, diagnosis and treatment, and while
by no means exhaustive, especially from a pathological stand-
point, the author has succeeded well in " giving a comprehen-
sive view of the subject," his object, as stated in the preface.

Bayle has estimated that myomata occur in 20 per cent of
all women over 2.5 years of age, while Kolh states that 40 per
cent of all women over 50 years, suffer from them. This very
frequency makes the subject one on which the general practi-
tioner should be well informed. Unfortimately however, many
text-books pive erroneous ideas, especially in regard to the
treatment of these tumors, so that it is a pleasure to find a
book, such as this, the recommendations of which can be safely
followed.

The introductory chapter takes up in a general way the clas-
sification, life history and the more important complications.

The chapter on anatomy contains an excellent section on the
vascular supply of the uterus, the relations of the pelvic or-
gans, and the alterations which rei5ult in these relations from
the development of tumors in various directions.

A concise tabulation of symptoms, which the author divides
into suggestive, characteristic, and contirmatory. tojrether with
the points to be sought for in the examination of the patient.
comprise a valuable chapter.

The most interesting sections are the 4th, on the develop-
ment, and the 5th, on the secondary changes in uterine meso-
dermic tumors. A review of the literature of the histogenesis
of sarcomata, myomata and telangiectatic tumors is given in
the former, while in the latter, the author discusses necrosis,
calcification, and inflammatory changes. He holds the view
advanced by Orth and Pfannensteil. that sarcoma commences
in myomata de nwo.and is not a degeneration, as we have been
taught by Virchow and Birch-Hirschfeld. Adeno-myoma is only
briefly considered.

A review of the long list of medicinal remedies which have
been used Is then given, the authors belief being that prolonged
medicinal treatment is useless.

We wish that the statements on electrical treatment, so
strongly recommended by Apostoll, Keith, Playfair and others,
were as decided as those in regard to medicines. " Undoubt-
edly in certain cases, it does produce a definite and reliable
effect, while in others it is entirely useless and extremely dan-
gerous. ... So long as it does not blind patient and surgeon
to the actual dangers of delay, in cases which ultimately re-
quire operation, so long will it be one of the really effective
weapons for use against the disease." Statements with which
few American surgeons will agree.

The chapter on surgical treatment is begun by empha.sis on
the fact that many cases require no treatment whatever.
" They are best treated by masterly inactivity." The history
of the evolution of the various operations is then given and
several pages devoted to the internal secretion of the ovary.
Myomectomy (the removal of the tumor per se, leaving the
uterus In situ) is recommended whenever practicable. For
hysterectomy, the author prefers the vaginal operation, when
the size of the tumor permits.

The 9th chapter contains many excellent points on general
technique. An exception must however be taken to the state-
ment in regard to gloves. " Cotton gloves can be boiled or
steamed before use, but it seems quite as difficult to sterilize
rubber gloves, as it is to sterilize the skin. They certainly

cannot be exposed to sufficient heat to render them germ
free." (Sic!).

The various operations are divided into (1) methods which
decrease the nutrition of the tumor; (2) methods which re-
move the tumor alone; (3) methods which remove the uterus
and the tumor; and the details of these operations reviewed.

Chapters on post-operative treatment and final results fol-
low and an excellent bibliography is appended.

Throughout, the text has been carefully prejiared and the
numerous cases cited are interesting and well selected. The
illustrations are fairly good but most of them have no clear
detail and are lacking in plastic effect. Figures 35, 36 and 37
are excellent.

B. R. S.

Atlas and Kpitonie of Ophthalmcitscopy and t)phtlialninsco|(ic
Biagnosis. By Prof. Dr. O. Haab, Director of the Eye
Clinic in Zurich. From the Third Revised and Enlarged
German Edition. Edited by Geo. E. de Schweinitz, Pro-
fessor of Ophthalmology, Jefferson Medical College, Phila-
delphia. With 152 colored lithographic illustrations and 85
pages of text. (Philad4^1iihki and London: W. B. Saunders
if- Co.. 1901.) Price, $3 net.

With the exception of von Graefe and Arlt no ophthalmolo-
gist in Europe possessed such gifts as a teacher nor left such
a strong impress upon his students as Horner of Zurich. One
finds his former assistants occupying high positions 'n ophthal-
mology all over the world.

As regards his industry and in a measure too as regards his
other gifts his mantle seems to have fallen upon the shoulders
of O. Haab who was once his assistant and who now occuines
the Chair of Ophthalmology in Zurich. Haab's work is a wel-
come addition to our armamentarium.

Most atlases of ophthalmoscopy while they give classic ex-
amples of the dift'ereut fundus affections seldom or at least to
a limited extent give us pictures of the deviations or rather
modifications of those pictures which are peculiarly charac-
teristic of the different diseases.

As a matter of fact the well-known picture of albuminuric
retinitis is seldom seen but we not unfrequently do see albumi-
nuria associated with marked changes in the retina, changes
which even if they are not arranged in the classic style have
quite the same significance.

The author has kept this point in view throughout and we
not only find the so-called typical pictures of well-known dis-
eases but also pictures which illustrate the subvarieties and
different stages of the same affection. Curious and very rare
ophthalmoscopic pictures are startling but from a practical
point of view they are unimportant and for this reas(Ui doubt-
less they occupy no space in Haab's collection.

A number of anatomical figures have been added to illus-
trate various microscopic conditions and this strikes us as
being very appropriate and at the same time a practical de-
parture from the ordinary run of similar works. Part first
consists of about sixty pages and is nothing more than a dis-
cussion of the general principles of ophthalmoscopy and is
about what we find in all text-books on the eye. Much that is
said in this chapter is illumined by the comments and sugges-
tions of the editor.

The mechanical part of the work is well done and the whole
is embodied in such handy shape as will contribute largely to
the success of the work.

R. L. 11.

August, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

267

An Atlas of the Medulla and Midbrain. By Florence R. Sabin,
it. D. (Hdltiiiioir: The Friedtviinilil Co., 1901.) Pages 112.

A stud}- of the labyrinth of the medulla by the student of
medicine is ever fraught with uncertainty and mi.sgivings on
his part. The anatomy is so complex, the details of the con-
nections of cell and nerve fibre are so complicated, that the
majority shrink from obtaining, from available text-book litera-
ture, even a superficial insight into its structure.

Dr. Sabin's model of the " relay station "' of the central ner-
vous system, now elucidated by a complete commentary, was
planned to meet the need for some " simple yet reliable meth-
od of aiding the students to obtain a reasonably clear idea of
the organ." The text, and plates from the model, the latter
from the brush of M. Broedel, fully achieve the purpose of the
author.

The eight plates accompanying the volume are all well
chosen, presenting clearly to the eye the gross structure of the
medulla. To more particularly call attention to each nucleus
of origin and fibre tract, and to impress them upon the mem-
ory, colors are used to differentiate the several parts, the effect
being at once striking and artistic.

The descriptions of the various gray nodes and fibre bands
are clear and comprehensive, and are sufficiently concise not
to be a drain upon one's time and beget hazy ideas of the
whole. Chapters V and VI upon the cerebral nerves and nuclei
of origin are not only the most interesting but the most per-
spicuous of the book.

Diseases of the Nose and Throat. By D. Braden Kyle, M. D.,
Clinical Professor of Laryngology and Rhinology, Jefferson
Medical College, Philadelphia; Consulting Laryngologist,
IJhinologist and Otologist, St. Agnes' Hospital. Second Edi-
tion. Kevised. Octavo. 646 pages; over I.'jO illustrations and
6 lithograiJhic plates. {PhiladeJphia and Louduii : 11'. li. Saun-
ders d Co., 1001.) Cloth, $4 net.

A review of the first edition of this excellent book appeared
in November last. In the present edition very few changes
have been made beyond the correction of typographical errors.
The work jiresents the subject of Diseases of the Nose and
Throat in a concise manner, keeping in mind the needs of the
student and general practitioner as well as those of the special-
ist. With the practical purpose of the book in mind, ex-
tended consideration has been given to details of treatment,
each disease being considered in full, and definite courses being
laid down to meet special conditions and symptoms. The work
is very valuable.

Essentials of the Diseases of Children. By William M. Powei l.
Third Edition. Kevised by Alfred Hand, Jr., Dispensary
Physician and Pathologist to the Children's Hospital, Phihi-
delphia. (Philmklphia: W. B. Haundcrs »(■ Co., I'JOl.)

To condense the present knowledge of any important di-
vision of medicine into a volume of two hundred and fifty small
pages and not omit much that is essential would be almost im-
possible and this is true of the present subject.

As the author points out much too little is said of diet and
general hygiene to convey the accurate knowledge their im-
portance demands — three and one-half pages Vicing given to
" Infant Feeding."

The discussion of the acute infectious diseases is quite as
good as the limited space will permit — thotigh it is hardly safe
to describe scarlet fever as a " somewhat contagious disease."

On the whole this third edition of Dr. Powell's book is quite
up to the standard of books of its class — but it is difficult to
see in just what these systems of questions and answers are
of benefit to either students or iiractitioners. The book is well
made and unusually free from typographical errors.

R. A. U.

Students' Edition, a Practical Treatise of Materia Medica and
Therapeutics, with special reference to the Clinical Appli-
cation of Drugs. By John V. Shoem.vker. M. D., LL. D., Pro-
fessor of Materia Medica, Pharmacology, Therapeutics, and
Clinical Medicine and Clinical Professor of Diseases of the
Skin in the Medico-Chirurgical College, of Philadelphia, etc.
Fifth Edition. Thorotighly Revised. I'ages vii-770. Extra
Cloth, $4 net. (Vhiliuldidiia : F. A. Datif: Cti.,1901.)

In this fifth edition of Dr. Shoemaker's well-known treatise
the pages have been thoroughly revised and many new subjects
added, but inasmuch as it is designed especially for students,
" nothing is included beyond a description of those drugs and
preparations which are official in the Pharmacopoeias of the
United States and Great Britain." Dr. Shoemaker has happily
e.xpressed the doses in the metric system, adding their equiva-
lents in the English system. This seems to be a very wise
procedure inasmuch as students can only be gotten to wi-ite
their prescriiitions in metric terms when they have to learn
their doses in that system. Our Pharmacopoeia has already
committed itself to this system and it is but the proper se-
quence that physicians should write their prescriptions in it.

The work is divided into two parts. Part one consisting of
seventy-four pages, deals with certain general considerations
of the subject introductory to the more detailed study of the
various drugs and their uses which follows in the second part.
These general considerations consist of definitions, the botani-
cal orders and names of the various medicinal plants, a few-
pages upon pharmacy and methods of making the various phar-
maceutical preparations; prescription writing; methods of ad-
ministration of drugs; poisons and their antidotes; etc.
Though briefly written, it contains many excellent suggestions.
Some exception may be taken to the author's use of the term
pharmacology, signifying the science of drugs, a study of their
natural history, their physical and chemical characters, and
the various methods of compounding and dispensing them.
Jlost authors prefer to limit this term definitely to the study
of the physiological action of drugs, and it seems to us that
this is decidedly a better word to apply to that subject than
the one here suggested of " Pharmacodynamics."

In iiart two the various pharmaceutical products are taken up
in aljihabetical order. Each is considered under several head-
ings. First its preparations are named; then under " Phar-
macology" a description of the drug is given, its source, its
physical characteristics, its solubility, reaction, etc.; under
" Physiological action " the substance is spoken of in relation
to its effects upon animals and man. Next follows the heading
Therapy where its usefulness in medicine is expounded; here
frequently a number of prescriptions are added. Part two em-
braces about 650 pages, closely written, and the numberless
products, many of which are of so little use in medicine, yet
so fully described, make it rather a forbidding book to place

268

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

in the hands of the student. At the same time the important
subjects are well considered and if the paragraphs upon the
therapeutic value of drugs are somewhat optimistic and hope-
ful, still it seems to be a very useful reference handbook to
the student who desires to have a full pharmacopeial armamen-
tarium for his practical work. Nothing- is said of such useful
therapeutic measures as hydrotherapy', climate, serotherapy,
etc., the book being absolutely limited to the consideration of
drugs and their administration.

It is to be hoped that some time there will arise a courageous
author who will write a book upon treatment in which only
really useful remedies, numbering probably over fifty, will be
spoken of in such a way that the future student may learn to
handle them effectively and scientifically, and the great bur-
den of remembering, even of looking through the scores of
utterly antiquated and useless preparations will be avoided.

H. B. J.

A System of Physiologic Therapeutics. Edited by Solomon
Soos Cohen, A. M., M. D. Vol. I, Electrotherapy, by Geokgb
W. Jacoby, M. D. In two books. Book I, Electrophysics.
163 illustrations. {Philadelphia: Blaklstnn's Son d Co., 1901.)
pp. xv-242.

The volume at hand is the first of a series which will com-
pose a system of phj'siologic therajieutics, embracing eleven
octavo volumes, devoted to the consideration of measures other
than medicinal, which experience has shown are beneficial in
the cure and prevention of disease. The appearance of such
a .system of medicine is timely as no author or authors have
until now, gathered together in one volume or series of vol-
umes, in English, these methods which are so very important in
the treatment of disease. The statement made at the sub-head-
ing of the title page really covers the scope of the work, " The
practical exposition of the methods other than drug giving
useful in the treatment of the sick." This first volume by Dr.
.Tacoby, "who is so well fitted to write upon the topic, is de-
voted to electrotherapy and is to be divided into two parts or
books, Book I being given up to the physical aspects of elec-
tricity with a description of the various forms of apparatus
that physicians are likely to use. The further volumes as the
announcement and the " foreword " of Dr. Cohen state, -wWl
consider Climatology and Health Hesorts; Nursing and Care of
the Sick; Diet; Hydrotherapy; Serotherapy; etc.

There is surely room for just such a set of books. We have
been too prone to think that we were teaching therapeutics
sufficiently when we taught our students the old materia
medica and the use of mere drugs, forgetful and careless of
the importance of the therapeutic value of the methods of
which this series of books vyill .speak. That the necessity of
this line of teaching has already come into the minds of some
men may be seen in Dr. Lauder Brunton's volume entitled
" Lectures on the Actions of Medicines," in which he not onlj'
writes upon various pharmaceutical products, but also devotes
many pages at intervals through the book to diet, massage,
counter irritants, hydrotherapy, poultices, etc.; and to the
minds of still others, as may be seen in the announcement of
one of our medical schools, where in speaking of its course
upon Practical Therapeutics, it states that the course teaches
among other things " the administration of practical therapeu-
tic measures, the use of massage, the preparation and useful
forms of diet, the care of patients considered from the nursing
point of view, the treatment of various emergencies, of special

diseases bj' climate, rest, and other practical procedures."
This course as advertised then practically epitomizes the work
which Dr. Cohen will embrace in his larger system of physio-
logic therapeutics. The volume before us opens with a fore-
word by Dr. Cohen on Therapeutics without Drugs, and com-
prises an argument for the need of such a series of books.
Here he justifies briefly the term " physiologic therapeutics "
by referring to Mr. Herbert Spencer's definition of life, main-
taining that the subjects to be treated in the forthcoming vol-
umes merely assist in aiding nature to preserve that noi-mal
equilibrium within its environment which constitutes health,
and therefore become physiologic in their curative action.

The use of drugs, on the other hand, for therapeutic purposes
he would term " artificial," inasmuch as through them there is
introduced into the organism substances ordinai-ily absent
therefrom and foreign to its composition. It is not his pur-
pose, however, to antagonize the latter therapeutic measures
in the least, for he admits " having a robust faith in the power
of good of the right drug, given in the right dose, at the right
time."

That every one will subscribe to all of Dr. Cohen's conclu-
sions I am inclined to doubt; for instance: on page ix there is
found the following paragraph: "The pathologic influence of
emotion is well shown in the evolution of exophthalmic goiter
and in the protean manifestations of hysteria, etc., etc." This
seems so far as the former disease is concerned rather a bold
statement, and I should be surprised to find that many would
admit the basis for the production of exophthalmic goiter was
to be found in an emotion. ■

The volume is devoted through 22.5 or more pages to a des-
cription of the terms used in electricity, the physical explana-
tion of electricity, the various methods of producing it, and
the arrangements for controlling-, measuring, and applying it.
The text is very fully illustrated and the subject presented so
clearly that one with little conception of the real nature of
the subject may get a fair idea of it. There is gathered to-
gether in this one volume knowledge which one could other-
wise only acquire through numerous books upon physic and
medical electricity, and to that extent it is extremely useful.
Nothing, however, in this part of Volume I is said upon the
therapeutic value of electricity; that topic, doubtless, being
reserved for part two of Volume I.

It seems questionable whether many medical men will
care to learn the various facts in regard to electricity which
are here set forth. It is knowledge for the electrician rather
than for the every-day practising physician; knowledge which
is necessary for one establishing an electro-therapeutic insti-
tution, but not for the man who applies the electrodes for
diagnoslie <ir llierapeutic purposes. From a mechanical point
of view the book is admirably gotten up. It is a credit to its
makers. The i)aper is heavy and fine; the printing clear, type
of good size, and well spaced, and the illustrations excellent.

It is greatly to be hoped that the connileted work will not
become so voluminous as to lose its general usefulness. Com-
pleteness with brevity, conciseness with lucidity shoxild be
the aim of all medical editors.

H. B. J.

Anomalies of Eefraction and of the Muscles of the Eye. By
Flayel B. Tiffany, A. M., M. D. Author's Fourth Edition.
{Kansas Citi/, Mo.: Hudson-Klmbcrly PuUishing Co., 1900.)

It was Job, we believe, who wished (hat his adversary had
written a book. If Dr. Tiifany has any adversaries, or, at all

AlGUST, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

269

events, anj' that are inclined to be critical, he has unquestion-
ablj- afforded them, in the publication of the book we are called
upon to review, such an opportunity as the great lamenter
must liave had in mind when he expressed this wish.

As the ■' reviews " which accompany the book state, it is
" elaborately illustrated "; and it contains unquestionably,
much useful information upon the subject of which it treats;
hut that it has been '" carefully revised," and the " few errors
[of the earlier editions] corrected," as is claimed in the pub-
lisher's notice, we are hardly inclined to concede. Indeed, we
have seldom glanced through a book that seemed to be so
sorely in need of what this one is supposed to have just re-
ceived— " careful revision," and though a " few errors " may
have been corrected there are a host of others still awaiting
elimination.

One of the first of these to attract our attention occurs in
the preface, and seems to have been handed down, without de-
tection, from the first to the present, fourth, edition. " Many
instruments and apparati" ' the author — unmindful of his de-
clensions— tells us, " have been invented," etc. Whether heter-
ophoria and ametropia deserve to be characterized, as they
are in another part of the preface, as " vast subjects .... still
wrapped in a halo of uncertainties " is, of course, a matter
simply of taste; and the same observation applies to this,
which we find on p. 69: " it is only when there is an appreciable
variation in the curvature that the eye is stigmatised (sic) as-
tigmatic."

The definition on p. 65 of an ametropic eye as one which
cannot focus parallel rays of light, " without an effort of
accommodation," is distinctly erroneous; for it is evident that
ametropia, so defined, would not include myopia. The state-
ment on p. 107 that " more or less choroidal blood-vessels may
be seen through the retina, especially in a dark-complexioned
person," is open to criticism upon more groimds than one; but
we shall content ourselves bj' pointing out that it is in blondes,
as a rule, that the choroidal vessels are most plainly seen, and
in brunettes that they are least distinguishable.

On p. 156 we read, with some surprise, " the hyperopic eye
is an undeveloped eye, with sight not up to the normal stand-
ard of distinctness for either near or distant objects "; but.

^ The italics here and in many other places in this re\iew are our own.

notwithstanding this unequivocal statement, we are told on
the following page that " the hyperopic eye of a moderate de-
gree with good power of accommodation may have the normal
amount of vision "; and, again, on p. 158, that " hypermetropes
with less than 3.50 D., with good accommodation, as a rule,
have ii or normal vision." On p. 159 we learn that " the
strongest glass that they [hypermetropes] require without the
use of a mydriatic indicates the manifest hypermetropia." It
is hardly necessary to point out that most young hyperme-
tropes, though a considerable part of their error of refraction
may be made manifest by painstaking ett'ort require no glass at
all to obtain normal distant vision. Quite as surprising is
the statement on the same page that " the manifest [hyper-
metropes] is usually apparent without a mydriatic."

Space does not permit us to call attention to all of the short-
comings which have arrested our attention in looking over the
pages of Dr. Tiffany's book; but, as examples of many others,
the following may be cited: "Hypermetropia can be cor-
rected, but may not be entirely cured" (p. 168). "Frequently
we have what is known as a spasm of accommodation, which
causes partial paralysis or paresis of the ciliary muscle " (p.
169). " It is now a conceded fact that hyperopia is often a
primary cause of . . . trachoma" (p. 170). Possibly " hyper-
boloidical glass," on p. 209, is a printer's error; but, if not, it is
evident there is still virgin soil for Dr. Gould to delve in. " It
is much better to under-correct [in performing a tenotomy]
and have to repeat the operation than to over-correct and be
obliged to advance the opposing (sic) muscle. " (p. 347).

Far be it from us to belittle the ill effects of eye strain,
whether due to refraction or muscular anomalies; but we can-
not but feel that the author has drawn an unnecessarily lurid
picture in thus describing the consequences of heterophoria:
" Life becomes a burden; despondency, melancholia, insomnia,
and suicide may be the end" (p. 230). And again, " in neu-
rotic and feeble patients the muscular errors or insufficiencies
may produce aphoria, diarrhoea, pains of the ovaries .... and
insanity even" (p. 233).

We are not surprised to learn, from the " reviews," to which
allusion has been made, that Dr. Tiffany's treatise is highly
thought of by jewelers and opticians and by the Philadelphia
" Optical College."

S. T.

STUDIES IN TYPHOID FEVER

SERIES I-II-III.

The papers on Tj'phoid Fever, edited by Professor William Osier, M. D., and printed in Volumes IV, V and VlIT of
The Johns Hopkins Hospital Reports have been brought together, and bound in cloth.

The price is $5.00 per copy. Only a few copies of the volume are on sale. Those wishing to purchase should address
their orders to the Johns Hopkins Press, Baltimore, Maryland.

270

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 125.

PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.

THE JOHNS HOPKINS HOSPITAL REPORTS.

Volume I. 423 pages, 99 plates.

Volume II. 570 pages, with 28 plates and figures.

Volume III. 766 pages, with 69 plates and figures.

VoLtJiJns^IV. 504 pages, 33 charts and illustrations.

■ * ^ '-'U^,, Report on Typhoid Fever.

By William .(Jfe'^R, M. D.. with additional papers by W. S. Tuaver, M. D..
and Ji- H^ETsox, M. D.

.,-. ' :" .■ Report in Nenrologry.

DemenUa Paralytica In the Negro Race; Studies In the Histology of the
■ titer; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic
Nerve Supply of the Cardiac Ventricles in Certain Vertebrates: The
Intrinsic Nerves of the Submaxillary Gland of Mux iMusoidis; The
Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements
of the Pituitary Gland. By Hesrt J. Berkley. M. D.

Report in Sureery.

The Results of Oneratlons for the Cure of Cancer of the Breast, from
June, 1889, to January. 1894. By W. S. Halsted, M. D.

Report In Gynecology.

Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic
Peritonitis; Tuberculosis of the Endometrium. By T. S. Ccllen, M. B.

Report in Pntlioloey.

Declduoma Malignum. By J. Whitridoe Williams, M. D.

Volume VII. 537 pages with illustrations.

Volume V. 480 pages, with 32 charts and illustrations.

CONTENTS:

The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewet-

soN, M. D.
A Study of some Fatal Cases of Malaria. By Lewellys F. Barker, M. B.

Stndles in Typhoid Fever.

By William Osler, M. D., with additional papers by G. Blumer, M. D.,
SiMOK Flexner. M. D., Walter Reed, M. D., and H, C. 1'arsoxs, M. D.

Volume VI. 414 pages, with 79 plates and figures.

Report in Neurology.

Studies on the Lesions produced by the Action of Certain Poisons on the
Cortical Nerve Cell (Studies Nos, I to V). By Henrv J. Berkley, M. D.

Introdurt'f^ ■ . — Recent Literature on the Pathology of Diseases of the Brain
by tne Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Exper-
imental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alco-
hol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning
(Ethyl Alcohol); Part II.— Serum Poisoning.— Experimental Lesions In-
duced by the Action of the Dog's Serum on the Cortical Nerve Cell;
Part III. — RIcin Poisoning. — Experimental Lesions induced by Acute
Rlcin Poisoning, 2. Experimental Lesions Induced by Chronic RIcin
Poisoning; Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical
Nerve Cell nroduced by the Toxine of Experimental Rabies; Part V. —
Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from
the Effects of Alcohol and Rlcin Intoxication; Nerve Fibre Terminal
Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Fatliolog-y.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent.

Thomas S. Ccllen, M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death, Probable

Migration of Ovum and Spermatozoa. By Thomas S. Cullen., M. B., and

G. L. Wilkins, M. D.
Adeno-Myoma Uteri DiCfusum Benlgnum. By Thomas S. Cullek. M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of

Infants. By William D. Booker. M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flesner. M. D.

L A Critical Review of Seventeen Hundred Cases of Abdominal Section
from the standpoint of Intra-peritoneal Drainage. By J. G, Clark,
M. D.
n. The Etiology and Structure of true Vaginal Cysts, By James Ernest
Stokes, M. D. , . ,, ,t .■

A Review of the Pathology of Superficial Burns, with a Contribution
to our Knowledge of the Pathological Changes in the Organs lu cases
of rapidly fatal burns. By Charles Rdssell Bardeen, M. D.
The Origin. Growth and Fate of the Corpus Luteum. By J. G.
Clark, M. D, .,,,„, r>

The Results of Operations for the Cure of Inguinal Hernia. By
Joseph C, Bloodgood, M. D,

III

IV.
V

Volume VIII. 558 pages with illustrations.

On the role of Insects. Arachnids, and Myriapods as carriers in the spread
of Bacterial and Parasitic Diseases of Man and Animals. By George
H. F, NuTTALL, M. D., Ph. D.

Studies In Typhoid Fever.

By William Osler. M. D., with additional papers by J. M. T. Finnkt, M. D.,
S. Flexner. M. D., I, P, Lyon, M, D., L. P. Hambcroer, M. D., H. W.
Cdshing. M. D.. J. F. Mitchell, M, D,, C. N. B. Camac. M. D , N. B. Gwtn.
M. D., Charles P. Emkrs.in. M.D., H. H. Tocng, M. D., andW.S. Tbatkr. M. 1).

Volume IX. 1060 pages, 66 plates and 210 other Illus-
trations.

Contribntions to the Science of Medicine.

Dedicated by his Pupils to William Henry Welch, on the twenty-fifth anniversary
of his Doctorate. This volume contains 38 separate papers.

Volume X. (Nos. 1-3 now in press.)

structure of the Malarial Parasites. Plate 1, By Jesse W. Laekar. Ml).

The Bacteriology of Cystitis. Pyelitis and Pyelonephritis In AVomen, with a Conaiderailon
of the Accessory EtlologlcalFactors in these Conditions, and of ihe Various Chemical
and Microscopical Questions Involved. By Thomas R. Brown. M.D,

Cases of Infection with Stronsryloldes Intestlnalls. (First Reported Occurrence in North
America.) Plates II and III. By Richard P. Strong. M.D. Price in paper. $1.50.

The 8et of nine volumes will be sold for fifty dollurs. net.
Volumes I and II ivill not be Hold seimrutely. VoIuuich 111,
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each. Volume IX n^lll be sold for ten dollars, net.

SEPARATE MONOGRAPHS REPRINTED FROM THE JOHNS
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Studies In Dermatology. By T. C. Gilchrist, M. D., and Emmet Rixford,
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The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and ,J.
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Studies in Typhoid Fever. I, 11. By William Osler, M. D.. and otliers.

E.xfracted from Vols. IV and V of The Johns Hopkins Hospital Reports. 1

volume of 481 pages. Price, in paper, $3.00.
Studies in Typhoid Fever. 111. By William Osler, M. D., and others,

E.Ntracted from Volume VIII of The Johns Hopkins Hospital Reports. One

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THE JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice;
abstracts of papers read and other proceedings of the Medical Society of the Hospital,
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BULLETIN

\ L-' ' ■' '' n V

OCT 8 1901

aO'^

THE JOHNS HOPKINS HOSPITAL

Vol. Xll.-No. 126.]

BALTIMORE, SEPTEMBER, 1901.

[Price, 15 Cents.

CONTENTS.

The History and Work of the Saranac Laboratory for the Study of

Tuberculosis. By E. L. Tuudeau, M. D., 371

The Prevention of Tuberculous Diseases in Infancy and Childhood.

By S. A. Knopf, M. D., 275

Respiratory Exercises in the Prevention and Treatment of Pulmon-
ary Diseases. By S. A. Knopf, M. D., 382

Pulmonary Tuberculosis in Baltimore. By H. W.\uken Buckler,

M. D., 388

Concerning a Definite Regulatory Mechanism of the Vaso-Motor
Centre which Controls Blood Pressure duriuu; Cerebral Com-
pression. By Harvey Cushino, M. D., 3'.)0

Pendulous Tubercles in the Peritoneum. By W. G. MacCallum,

M. D., 393

Summaries or Titles of Papers by Members of the Hospital and

Medical School Stail'Appearing Elsewhere than in the Bulletin, 395

Proceedings of Societies :

The Johns Hopkins Hospital Medical Society, 295

The Parasite of Cancer, with Demonstrations jDr. Gatlord]; —
A Case of Pseudo-parasitism LDr. Stiles] ; — E.xhibitiou of Medi-
cal Cases; A Case of Charcot's Joints involving both Knees
[Dr. FutcuerI; — Protozoie and Blastomycetic Dermatitis, with
Lantern-slide Demonstrations and Exhibition of a Case [Dr.
GiLcinuST] ; — Exhibition of Medical Cases [Dr. Osler] ; — Drain-
age of the Bladder and Cystoscopic Examinations [Dr. KellyJ;
— Observations upon Smallpox [Dr. Pouter]; — Fibrinous
Bronchitis [Dr. Bettmann] ; — The Life History of Drepauidium
IDrs. Durham and Myers].

Notes on New Books, , . . . 301

THE HISTORY AND WORK OF THE SARANAC LABORATORY FOR THE STUDY

OF TUBERCULOSIS.'

By E. L. Trudeau, M. D., Saranac Lake, N. Y.

Gentlemen : — I feel much as a scout, who had been doing
duty alone on some frontier for many years, might feel when
suddenly brought into the presence of a well organized army,
and I assure you I appreciate the privilege of addressing you.
I must apologize for talking of my own work, but the necessi-
ties of the situation make this more or less unavoidable. My
experiences may prove an encouragement, perhaps, to those
of you who are to locate at distant points, as demonstrating
the possibility of doing scientific work in remote regions, far
from the centres of learning, and they may prove of interest
to a Society such as yours as describing the foundation of the
first laboratory in this country devoted to researches in
tubercidosis.

I had from the first many difficulties to contend with; no
health, no scientific training, no apparatus, no access to
books, and was situated forty-two miles from a railroad, in a
primitive forest, where I had gone in search of health.

'Read before The Laennec, a Society for the Study of Tuberculosis at
the Johns Hopkins Hospital, May 1, 1901.

My insi^iration was Koch's jiaper on the Etiology of Tuber-
culosis, of which I read an extract in a medical journal in
1883, and which was translated into English and sent me by
a patient. In some of the short visits I was enabled to make
to New York, Dr. Prudden taught me how to stain the
bacillus, and the first principles of bacteriology, and I taught
myself the rest as best I could.

My laboratory was a very small room in my house, in
which, during the intense cold of winter, water generally
froze at night, in spite of my best efforts, as we had no coal
in Saranac Lake in those days, and the wood stove could
not be counted upon to burn all night. I had no apparatus
but my microscope. AVith Dr. Koch's paper as a guide, I
succeeded, however, in growing the tubercle l)acillus in a
homemade thermostat, which had no regulating apparatus,
and wbich was heated by a small kerosene lamp only. In
order to protect this from the violent changes of temperature,
which occurred jirincipally at night, I had enclosed it in a
scries of wooden boxes, the doors of whicli could be opened

272

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 12C.

or closed at will, according to the intensity of the cold out of
doors. But on very cold nights I was obliged to get up in the
night to make a fire in the stove in order to prevent too
violent changes of temperature in my little oven.

With these primitive arrangements, after many failures,
I obtained the tubercle bacillus in pure cultures, being, I
believe, the second observer in America to do this; Dr.
Sternberg, while himself located on the frontier, in a far
distant military post, having siicceeded in accomplishing this
nearly a year before I did. With these cultures I repeated
all Koch's inoculation experiments.

My guinea-pigs had to be kept in a hole under ground
heated by a kerosene lamp, this being the only spot in
Saranac Lake where they could escape freezing at night.

My first publication," in 1886, was a record of experiments
demonstrating the infectiousness of bacillary spirtum, and
the harmlessness of expectoration free from bacilli taken
from a patient supposed to have consumption.

In 1886 I also studied the influence of extremes of envi-
ronment on the course of inoculation tuberculosis, and pub-
lished the results in a paper entitled " Environment and its
Eelation to Bacterial Invasion in Tuborciilosis.'" Many of
my inoculated rabbits allowed to nm wild on an island recov-
ered, or developed only a localized disease, while those placed
under the most unhygienic conditions I could devise, all died
of tuberculosis within three months. The results of this
research increased my confidence in the influence of a favor-
able environment on the course of the disease, and confirmed
my faith in the value of the sanitarium and open-air method
of treating tuberculosis, of which I was then making a prac-
tical application in the establishment of the Adirondack Cot-
tage Sanitarium.

During the same week in which Koch's announcement of
the discovery of tuberculin and of his hopes as to its specific
curative action on tuberculosis, was flashed across the ocean
and created in medical circles an excitement which has never
been equaled, I published in the Medical Eecord* an article
describing my attempts at the production of artificial im-
munity in animals by the injections of sterilized and filtered
liquid cultures of the tubercle bacillus (tuberculin), and my
failure to obtain any appreciable degree of immunity by this
method.

Shortly after this time Dr. E. R. Baldwin came to Saranac
Lake in search of health, and while at the Sanitarium began
to help me with my experiments. How efficient a helper he
has proved his own published work testifies, and the Labora-
tory at Saranac Lake owes much to his unselfish devotion to
science.

About this time, while ill in New York, my house burned
to the ground, the fire having originated during the night
from the explosion of the kerosene lamp of the thermostat
in my little laboratory, and everything in the house and
laboratory proved a total loss. Two days after the fire I

« American Journal of Medical Sciences, October, 188.5.
3 American Journal of Medical Sciences, July, 1887.
■•Medical Record, November 33, 1890.

received from Dr. Osier a brief note, which shows that his
great reputation should not be limited to his attainments as
a physician, but that he may lay claim also to some reputa-
tion as a prophet. The entire substance of the note was
as follows :

"Deah Teudeau: — I am sorry to hear of your misfor-
tune, but, take my word for it, there is nothing like a fire to
make a man do the Phoenix trick."

Dr. Osier's prophecy very soon began to be realized. A
friend and patient of mine, Mr. George C. Cooper, called on
me the day after the fire, and after expressing his sympathy,
told mc that as soon as I was well enough he hoped I would
return to Saranac Lake and build a suitable laboratory; one
that could not burn down. That he wanted me to build the
best I could plan for the purpose, and that he would pay for
it. The photographs I show you illustrate how I availed
mj'self of his generous offer.

The building is of cut stone, slate, glazed brick, and steel,
completely fireproof, lit by electricity, heated by hot water,
supplied with its own gas machine for the thermostats. Bun-
sen burners, and sterilizers, and furnished with every appli-
ance for bacteriological and chemical work. It has a library
which was donated by the late Mr. Horatio Garrett, of Balti-
more, while the continuance of the experimental work so far
has been made possible through the generosity of the late Mr.
George Cooper, Miss Cooper, Mr. John Garrett, Mrs. A. A.
Anderson, and others, who from time to time have given
sums of money to defray the necessary expenses. It is purely
a research laboratory, sells no products, and has now a legal
standing, having been incorporated lately as the Saranac
Laboratory, according to the laws of the State of New York.
It has as yet no endowment, and is still dependent on the
efforts of its founder for the funds necessary for its main-
tenance, but will, I hope, some day be endowed.

While the Laboratory was in process of construction a
small addition to my stable was hastily built, and served as
a temporary laboratory, in which for a year the work, thanks
to the generosity of Mrs. Robert Hoe, was continued.

Much time was at first naturally enough devoted to the
self-education of the stafl' of the Laboratory, to the study of
the various culture-media proposed from time to time, and to
perfecting our technic. A good deal of the work of the
Laboratory has been given to testing experimentally all pro-
posed specific methods of treatment and all consumption
cures. The outlook, at first, seemed to tend toward the appli-
cation of germicidal substances, and many experiments, which
all proved barren of results, were made in this direction. We
soon learned that the tubercle bacillus bore " cheerfully "
a degree of medication which proved fatal to his host. We
found that creosote, iodoform, sulphureted hydrogen, hydro-
fiuoric acid, essence of peppermint, and other germicides
proposed as cures, while they had no infiuence on the tuber-
culous process, often tended to shorten the lives of the
treated animals. The publication of these researches, how-
ever, had some infiuence in disproving the claims of these

THE JOHNS HOPKINS HOSPITAL BULLETIN, SEPTEMBER, 1901.

PLATE XXXII

Sarauac Laboratory for the Study of Tuberculosis. Built iu 1894.

luterior of Sarauac Laboratory tor the Study of Tuberculosis.

Septembee, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

273

specifics, and in preventing to a certain extent their more
general application to the treatment of the human subject.

The next phase of our work was that which was devoted
to attempts at the production of immimity by injections of
sterilized attenuated cultures, and by the study on animals
of the influence of treatment with toxines derived from the
bacillus, and modified according to various methods proposed.

The claims made for the various tuberculins put forth by
Koch, Hunter, and others, Klebs's antiphthisin and tubercu-
locidin, and Koch's T. E. tuberculin, as well as the different
serimis said to contain antitoxines capable of neutralizing
the toxines of tuberculosis, were all tested in turn in many
experiments, while for several years Dr. Baldwin and I, by
various methods, attempted to produce a serum from rabbits,
sheep, and asses, in which we could demonstrate the presence
of antitoxine. Neither our serums nor any of those proposed
by other experimenters were found capable of saving the
tuberculous guinea-pig from a fatal dose of tuberculin.

At the time Koch published his paper on T. R. tuberculin,
a study of some of the first bottles imported was made by
Dr. Baldwin and myself, and demonstrated in this material
the presence of living tubercle bacilli capable of infecting
guinea-pigs, and enabled me to avoid the use of this substance
at the time in the treatment of patients at the Sanitarium.
No doubt the publication of our observations also prevented
its general use until the defects in the technic of its manufac-
ture had been remedied.

The tuberculin test and the mechanism of the tuberculin
reaction have formed the subject of many of our studies,
which have tended to demonstrate the reliability of the tuber-
culin test, and its apparent freedom from dangerous after-
effects, and which have helped to throw some light on the
mechanism of this reaction.

The studies made by Dr. Irwin H. Hance of the dust taken
from all the buildings at the Sanitarium, showed that, with
one exception (in a cottage in which a patient had been
reported for expectorating on the floor), the dust tested was
absolutely free from infectious properties, and this afforded
experimental evidence that the methods adopted in the insti-
tution, to protect the patients from re-infection, were effica-
cious.

Dr. Baldwin has recently pointed out the possibility of
infection of the hands of consumptives, and demonstrated the
presence of living tubercle bacilli on the hands of patients
using handkerchiefs, and their absence generally from the
hands of Sanitarium patients who made use of the paper cus-
pidors.

Some of the papers published by my co-workers from the
Laboratory have been as follows:

1. The Effect of Peppermint Inhalation on Experimental
Tuberculosis. E. R. Baldwin. New York Medical Journal,
May 18, 1895.

2. Effect of Antitubercle Serum in Experimental Tuber-
culosis. S. W. Hewetson. New York Medical Journal,
Nov. 9, 1895.

3. A Study of the Infectiousness of the Dust in the

Adirondack Cottage Sanitarium. Irwin H. Hance. Medical
Record, December 28, 1895.

4. A Gift of Philanthropy to Science (The Saranac Labor-
atory for the Study of Tuberculosis). E. R. Baldwin. Sci-
entific American, March 6, 1897.

5. Infection from the Hands in Pulmonary Phthisis. E.
R. Baldwin. Philadelphia Medical Journal, Dee. 3, 1898.

6. Preliminary Communication on the Bio-Chemistry of
the Bacillus Tuberculosis. P. A. Levene. Medical Record,
Dec. 17, 1898.

7. A Case of Lymphatic Leukemia Combined with Pul-
monary Tuberculosis. E. R. Baldwin and J. A. Wilder.
American Journal of the Medical Sciences, June, 1899.

8. The Conditions of Tuberculoiis Infection and Their
Control. E. R. Baldwin. Yale Medical Journal, March,
1900.

9. The Results of Sanatoria and Special Hospital Treat-
ment in Pulmonary Tuberculosis. H. McL. Kinghom.
Montreal Medical Journal, July, 1899.

10. Some Retinal Complications in Chlorosis. H. McL.
Kinghorn. Montreal Medical Joiimal, January, 1900.

11. Symptoms of Renal Tuberculosis. H. McL. King-
horn. Montreal Medical Journal, March, 1901, besides twentj
papers by myself, the titles of which I will spare you."

5 Publications by E. L. Trudeau, as follows:

I. An Experimental Research upon the Infectiousness of Non-
Bacillary Phthisis.— Amer. Journal of the Med. Sciences, October, 1885.

3. Environment in its Relation to the Progress of Bacterial Inyasion
In Tuberculosis.— Amer. Journal of the Med. Sciences, July, 18S7.

3. Hydrofluoric Acid as a Destructive Agent to the Tubercle Bacillus —
Medical News, May 5, 188S.

i. Hot-air Inhalations in Pulmonary Tuberculosis.— Medical News,
September 38, 1889.

5. Some Cultures of the Tubercle Bacillus, Illustrating Variations in
the Mode of Growth and Pathogenic Properties.— Transactions of the
Assoc, of American Physicians, 1890.

6. An Experimental Study of Preventive Inoculation in Tuberculosis.
—Medical Record, November 23, 1890.

7. The Treatment of Experimental Tuberculosis by Koch's Tuber-
culin, Hunter's Modification, and other Products of the Tubercle
Bacillus.— .Medical News, September 3, 1893.

8. Results of the Employment of Tuberculin and its Modifications at
the Adirondack Cottage Sanitarium — Medical News, September 10, 1893.

9. Eye Tuberculosis and Anti-tubercular Inoculation in the Rabbit. —
New York Medical Journal, July 32, 1893.

10. A Report of the Ultimate Results Obtained in Experimental Eye
Tuberculosis by Tuberculin Treatment and Anti-tuberculouslnoculatiou.

— Medical News, September 29, 1894.

II. A CUetoical and Experimental Research on "Antiphthisin"
(Klebs). (By E. L. Trudeau and E. R. Baldwin.)— Medical Record,
December 31, 1895.

13. Sanitaria for the Treatment of Incipient Tuberculosis. — New
York -Medical Journal, February 37, 1897.

13. The Tuberculin Test in Incipient and Suspected Pulmonary Tu-
berculosis.—Medical News, May 39, 1897.

14. The Need of an Improved Technic in the Manufacture of Koch's
"T. R." Tuberculin. (By E. L. Trudeau and E. R. Baldwin.)-Medical
News, August 38, 1897.

15. Remarks on Artificial Immunity in Tuberculosis.— British Medical

Journal, December 35, 1897.

10. Experimental Studies on the Preparation and Efi^ects of Anti-

274

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

Most of my own work has been devoted to the study of
methods which might tend to jDroduce artificial immunity,
and has generally proved barren of definite results. All ray
attempts at inducing artificial immunity by the methods
claimed by others to have been successful in immunizing
guinea-pigs and rabbits were also negative. I learned by
practical experience that toxine immunity and bacterial im-
mimity in tuberculosis do not go hand in hand. While I
could accustom my animals, by gradually increased doses at
intervals, to bear without apparent injury, amounts of tuber-
culin and other toxic products of the tubercle bacillus which
at first woidd have proved rapidly fatal, I found that this
toxine immunization did not protect the animal against the
invasion of his tissues by the bacilli when subsequently inocu-
lated with them. The only observation I made from all
this work which was in the least encouraging was obtained
by preventive inocidations of cultures attenuated by many
years of continuous growth on artificial media, and my results
along these lines confirmed those of De Schweinitz.

By prolonged growth a culture is obtained which is not
in the majority of cases fatal to rabbits, and only relatively
so to guinea-pigs, many animals living over a year after the
protective inoculation, and showing then only evidences of
slight and localized tuberculosis. AVlien reinociilated with
virulent bacilli, guinea-pigs thus protected live about four
times as long as the controls, though they all ultimately die.
In rabbits thus vaccinated, and subsequently reinoculated
with virulent tubercle bacilli, in the anterior chamber of the
eye, the reaction produced by the virulent germs is very differ-
ent from that noticed in the controls. In the controls, the
introduction of the virulent bacilli in the anterior chamber
produces at first little apparent irritation, and a couple of
days later the eye shows no inflammatory reaction, and looks
about normal. Little by little, however, tubercles begin to
develop, and the conjunctival vessels become turgid, thel
cornea opaque, the intraocxdar pressure increases, and the
eye goes on to more or less complete destruction. In the
vaccinated animals, on the contrary, the virulent inoculation
is almost at once followed by a violent inflammatory reaction,
intense vascular congestion, and cloudiness of the cornea,
which little by little subsides, at just the time when the
eyes of the controls are rapidly getting worse. The tuber-
culous process in many instances seems aborted, and tlie eye
restored, if not to its original integrity, at any rate witli but
little permanent destruction of the tissues involved. Tliis

toxins for Tuberculosis. (By E. L. Trudeau and E. H. Baldwin.)— Amer-
Journal of the Med. Sciences, December, 1898, and January, 1890.

17. The Adirondack Cottage Sanitarium for the Treatment of Incip.
ient Pulmonary Tuberculosis The Practioner, February, 1899.

18. The Present Aspect of Some Vexed Questions Relating to Tuber-
culosis, with Suggestions for Future Research Work.— Johns Hopkins
Hospital Bulletin, No. 100, July, 1899.

19. The Sanitarium Treatment of Incipient Pulmonary Tuberculosis
and its Results. — Medical News, June 3, 1900.

ao. The First People's Sanatorium in America for the Treatment of
Pulmonary Tuberculosis.— Zeitsehrift fiir Tuberkulose und Heilstatteu-
wesen, vol. 1, No. 3, 1900.

does not take place in all animals, but in the greater pro-
portion of them.

The encouraging feature of these results lies in the fact
that some influence has been produced by the preventive
inoculations (which usually are best made intravenously), so
that the reaction of the tissues to the test inoculation is not
the same as in the controls. This peculiar reaction of the
tissues to the test inoculation would seem to be due to a
certain degree of acquired immunity, as in other bacterial
diseases in which artificial immunity can be produced, as
in anthrax, we find a violent local reaction of the tissues in
the vaccinated animals; a reaction which seems to abort the
occurrence of general infection, while in the controls the local
reaction is wanting, and the disease runs an uninterrupted
course.

Throughout all these j'ears, the results obtained in the
Laboratory have been applied practically to the development
and perfecting of the sanitarium treatment, and have given
us a rational basis for the methods adopted there. The
demonstration of the favorable influence of environment on
the course of the experimental disease; of the actual protec-
tion from infection afforded by the methods adopted at the
Sanitarium to this end; of the danger of hand infection by
the handkerchiefs of consumptives; of the necessity of testing
thoroughly, on animals, any specific method of treatment
proposed before making use of it in the human subject, as
evidenced by our experience with T. E. tuberculin; of the
value of the tuberculin test in the detection of the disease,
and its relative freedom from danger as shown by the experi-
mental disease in animals, are all examples of the application
of knowledge gained in the Laboratory, to tlic practical im-
provement of our methods of dealing with the disease in the
human subject.

While the modern sanitarium represents the practical appli-
cation of what we have learned and already know, tlie labora-
tory represents what we still hope to accomplish. It is to
the laboratory and to research work that we must look if we
are to advance in our struggle against tuberculosis; and the
importance of forming such societies as yours, and of founding-
laboratories for research, where facilities for original work
are at hand, and where, if need be, the living expenses of the
workers may be defrayed, cannot, in my opinion, well be
exaggerated.

In conclusion, allow me to bring to your attention, briefly,
some of the more interesting researches as yet unpublished,
which have been carried out at the laboratory this winter,
principally by Doctors Levene and Baldwin, and which were
made possible by the generosity of Mrs. A. A. Anderson.

Dr. Phoebus A. Levene, with the assistance of Dr. E. E.
Baldwin, who furnished him with the enormous quantity of
germs necessary for his chemical analysis, set himself the
task of making wliat may be termed a chemical dissection
of the tubercle bacillus. Much work on the chemistry of
the tubercle bacillus has been done already by Behring, Ham-
mcrsclilag, Hoffman, De Schweinitz, and Euppel. As a result
of Dr. Levene's work I show you in these flasks the various

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

275

substances which he has thus far been able to isolate from
the dried and crushed germs. The first flask contains a
coloring matter, an alcoholic extract, of the washed, dried,
and powdered bacilli. That this coloring matter is peculiar
to the tubercle bacillus seems to be indicated by the fact that
a few drops of it added to a glass of water give the same
opalescent, yellowish green hue which is noticed in cultures
growing on transparent liquid media.

He also separated a peculiar fat, or wax-like substance,
which I now show you, and which forms thirty per cent, of
the body substance of the bacillus, ^\^len the various com-
ponent parts of the bacillus are stained, this is the only one
which holds the stain in the presence of acids. It does not
seem to be a toxine which causes the fever, since Dr. Baldwin
demonstrated that animals inoculated with bacilli freed from
fat react to tuberculin in the usual way.

Dr. Levene also separated three nucleoproteids which have
different coagulation points. From these he obtained a
nucleic acid, which I now show you, and which he found to
contain more phosphorus than nucleic acid derived from
other animal and vegetable substances which he tested. The
nucleo-proteids of the tubercle bacillus are probably the toxic
agent, or at least one of the toxic substances, contained in the
bacilli. This was demonstrated in a set of experiments I will
refer to again, where the toxicity of tuberculin was shown to
be destroyed l)y those ferments which are known to be spe-
cially active in splitting up nucleoproteids.

Besides these substances. Dr. Levene found a glycogen,
or a glycogen-like substance, which is contained in this small
flask. This is the first time, to my knowledge, that this sub-
stance has been demonstrated in the tubercle bacillus, though
the presence of carbohydrates has been suspected as a neces-
sary source of energy.

He also studied the chemical differences in cultures grown
on different media, in virulent and less virulent cultures, to
determine the relation the chemical composition of bacteria
might bear to their virulence. Comparative studies were
made of bacilli grown on ordinal^ bouillon, and on a syn-
thetic medium described by Proskauer and Beck, containing
chiefly phosphates, maunit, and glycerin. Results show that
more fat and a larger amount of proteid and free nucleic acid
could be obtained from bouillon than from mannit cultures,
and it would appear that toxic properties of bacillus are prob-
ably related to the nucleic acid and its combinations which
they contain.

Another interesting set of experiments by Dr. Levene and
Dr. Baldwin proved that the toxins of tetanus, diphtheria,
and tuberculosis, are all destroyed by digestion with trypsin,
and the first two by pepsin and papain also. Wien thus
treated, tenfold fatal doses were harmless. Tuberculin could
not be destroyed entirely by peptic digestion, and it is prob-
able from this fact that it is a nucleo-proteid, this group of
proteids being more resistant to pepsin.

THE PREVENTION OF TUBERCULOUS DISEASES IN INFANCY AND CHILDHOOD/

Bt S. a. Knopf, M. D., New York City.

Before entering my subject I desire to express my most
heartfelt thanks to your Professors, Welch and Osier, who
honored me with the invitation to deliver these lectures before
you. To lecture to an audience composed of students and the
post-graduate class of Johns Hopkins Medical School, which
to-day stands as an example of what is understood to be the
highest type of the medical department of a university, not
only in this country but also abroad, is a privilege which, I
assure you, I appreciate most highly.

As the title of my address indicates I have chosen to dis-
cuss before you to-night the Prophylaxis of Tuberculosis
During Childhood. The importance of this subject I hardly
need to emphasize, for the prevention of tuberculosis in chil-
dren is one of the most essential factors in the solution of the
tuberculosis problem.

You know of the prevalence of this scourge in the human
race. Everyone of you knows some family in which one or
several members are suffering from this disease, and others
in which for two or three generations it has been considered

'Lecture delivered before the Senior and Post-graduate Classes of
Johns Hopkins Medical School, May 38, ItlOl.

the family affliction, are not rare. The members of those
unfortunate families are very often spoken of as having in-
herited consumption or phthisis pulmonalis.

Let us, for a moment, summarize what we really know of
a direct hereditary tuberculous disease. Bacillary transmis-
sion, coming directly from the paternal side through sperm,
has been experimentally demonstrated. Clinically, however,
the cases are exceedingly rare. According to Lartigau '
there are only four reported cases, and even in these it was
possible that there was hereditary predisposition with subse-
quent bacterial infection. Benda thinks spermatozoa inca-
pable of transporting immotile bacilli. Walter' examined
microscopically 230 different preparations from testicles and
63 from prostate glands, coming from 21 patients who had
died of pulmonary tuberculosis, and could not find a single
bacillus in any one of them.

The extreme rarity of primary genital tuberculosis in
vamna or uterus seems the best clinical evidence that direct

' " Congenital Tuberculosis," Twentieth Century Practice of Medicine,

vol. XX.

'Cornet, "Die Tuberkulose," Berlin, 1899.

276

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

paternal bacillary transmission of tuberculosis practically does
not exist.

Maternal bacillary transmission, on the other hand, can
take place through the placenta and perhaps even through
the OTum. Forty such cases of indisputable congenital tuber-
culosis traceable to maternal origin are now on record. This
number, however, is infinitesimally small compared with the
number of authentic cases where the child of a tuberculous
mother has been carefully examined without finding the
slightest trace of tuberculous disease, either clinically, bac-
teriologically, or pathologically.

Straus,* who has made extensive experiments in this direc-
tion, repeatedly transplanted portions of the various organs
of a fetus from a mother in the last stages of consumption
into guinea-pigs and never succeeded in producing tubercu-
losis in these animals. Von Leyden" failed akewise in his
experiments to inoculate tuberculosis with organs taken from
a child which had died a few minutes after birth and which
had a consumptive mother. Noccard," who only experi-
mented with animals, took the organs of 32 fetuses from four
tuberculous rabbits and right tuberculous guinea-pigs, and
inoculated 32 guinea-pigs, all with negative results.

Thus it seems to us that we might consider direct bacillary
transmission, even from the maternal side, so exceedingly
rare as to leave it outside of consideration in studying how
to prevent tuberculosis in childhood. Let us rather assume
two cardinal points; first, that tuberculous infection con-
tracted in whatever way during infancy or childhood comes
from without and not from within. Secondly, that there
may, however, exist a hereditary predisposition to tubercu-
losis. How this predisposition is brought about I do not
wish to attempt to explain. It is, however, I believe, reason-
able to suppose that the toxins secreted by the bacilli in the
lungs of a tuberculous mother and the general debility caused
by them, impair often quite seriously the development of the
child in utero.

As to the frequency of tuberculosis in childhood I will not
burden this little address with many statistics. Permit me
only to quote a few of the more interesting ones. Bollinger '
in 500 autopsies of children of all ages up to the fifteenth
year found lesions of tuberculosis in 218 cases. In 150 of
these the lesions were active and in 68 latent.

As to the time when children manifest the symptoms of
tuberculosis most frequently, Heubuer's* statistics are in-
structive. Of 844 infants of which none suffered from tuber-
culosis at the time of their reception in the hospital, the
development of the disease took place in 3.6;^ at the age of
3 to 6 months, io 11. 8;/ at the age of 9 months, in 26.6^ at
the age of one year.

■■Straus, " L.1 tuberculose et son bacille."
6 Zeitschrift f. klin. Medicin, Bd. Tiii, 1884.
' Anuales des med, exp., vol. i, 1889.

'D'Espine, Aunales de med. et de chir. infantile; September 1, 1900.
8 " Zur Verhiituug der Tuberkulose im Kindesalter," Congress of
Tuberculosis. Berlin, 1809.

.376 "

13.4

30H "

11.1

470 "

7.4

683 "

.5.0

years.

3 "

4 "
.5-6 "
7-10 "

Let US incidentally remark that even these statistics seem
to prove that children are very rarely born tuberculous. We
know from animal experiments that the grosser pathological
changes, brought about by the bacillus of tuberculosis, such
as enlargement of the glands, are not produced before two or
three months after the penetration of this micro-organism
into the system.

According to Kiiss ° the maximum death rate from tuber-
culous lesions in childhood is reached between the second
and fourth years. As to the modus operandi of the infection
of children we have, of course, no statistics. To ascribe the
very frequent intestinal tuberculosis found in childhood ex-
clusively to a tuberculous milk supply would be unscientific.
There is no doubt that many a child has been rendered
tuberculous because of taking food coming from tuberculous
cows, but in as many, perhaps even in more cases, intestinal
tuberculosis is secondary and has resulted from the ingestion
of pulmonary secretions, since small children never expecto-
rate. Autopsies seem to show that a very large percentage
of children have contracted tuberculosis by inhalation since
the bronchial glands harbor the oldest foci and seem thus
to represent the point of entry of the tuberculosis bacilli.
The presence of bronchial and pulmonary foci and tubercu-
losis of the mesentery glands, when all lesions seem to be
of the same duration, may well be explained by a double
infection of the respiratory and alimentary tract of the child.

A more recent explanation of the frequent presence of
tuberculosis in the bronchial glands as being also probably
due to the ingestion of tuberculous milk, is given by Latham.'"
According to this author the bacilli pass from the intestinal
mucous membrane, by way of the lymphatics, to the brou-
I'liial glands. From these glands the process spreads to the
lung tissue, 1, by direct continuity; 2, by means of the lym-
phatics but against the supposed lymphatic stream; 3, by
ulcerating into a blood-vessel and in this way disseminating
the bacilli all over the body; and 4, by ulcerating into a
bronchus. The right set of glands is more commonly affected
than the left. Latham, whose observations cover more than
3000 cases, admits, however, a very frequently infected air
supply as a cause of tuberculosis in childhood. Thus we see
that in young as well as in old, tuberculous infection can
take place in three ways, namely. Inhalation, Ingestion and
Inoculation.

The presence of a consumptive who is careless with his
expectoration is sufficient to endanger the life of a child;
and it is not at all necessary that the child should come in
close contact with this individual. Heubner speaks of num-

' Kiiss, " De FHer^ditr- parasitairc de la tubcrcuiose hnmaine,"
Paris, 1898.

'" Liitbani, "Pulmonary Tuberculosis iu Early Cliildliood," Lancet,
December 22, 1900.

Septembee, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

277

erous cases where children from healthy parents given into
a family to board became tuberculous owing to the presence
of a consumptive in that family.

The sputum coming from a tuberculous mother, father,
relative or friend is a very frequent cause of the infection
of little infants. Here the infectious germs may be ingested
by the child with its saliva, but being kissed by tuberculous
individuals is not the only source of the ingestion of tuber-
culous saliva. Midwives and sometimes also physicians will in
the presence of an asphyxiated newborn child apply their
mouth to that of the infant and inflate the child's chest to
bring its respiratory organs into play. If the operator is
consumptive the danger of imparting his or her disease to the
infant is evident. In my recent book on tuberculosis " I
quoted the remarkable case of Eeich, which, I believe, will
bear repeating here as an illustration: A midwife in the vil-
lage of Neuenberg became consumptive in 1874, and died
of this disease in July, 1876. Ten children, without heredi-
tary predisposition, attended by this midwife between April,
1875, and May, 1876, died before reaching the age of seven-
teen months. This consumptive midwife was in the habit
of sucking the mucus from the mouths of newborn children,
and blowing air into their mouths when there was the slightest
sign of asphyxia.

I was assured by a tuberculous mother that since the family
physician had warned her never to kiss the child on the
mouth, she had religiously refrained from doing so; but while
telling- me of this devotion I saw her tasting the food she
was preparing for the child, to Judge of its palatability and
temperature, from the same spoon with which she fed her
infant. In like manner the rubber nipple of the milk bottle
may also become a source of infection.

Inoculation during early infancy is relatively rare, if we
leave aside the comparatively numerous cases of tuberculous
infection through ritual circumcision. I have been able to
collect about twenty authentic cases, but the surgical litera-
ture of all countries where Israelites practice this rite in the
orthodox way, continues to contain reports now and then of
cases of tuberculous infection through this mode of circum-
cision. The tuberculous inoculation following this operation
manifests itself first as a local disease of the genital organs
from whence it becomes geueralized in a groat number of
cases. The operation of circumcision, when skillfully and
carefully performed, is in itself trifling, but the sucking of the
prepuce afterwards makes it dangerous, for it is evident that
if the operating rabbi should be a consumptive, inoculation
is made very possible.

So much for the dangers to which the infant is exposed.
When the child becomes old enough to creep about and
play on the iloor it is exposed to all three methods of infection
at once. If there is a consumptive in the family and he is
careless, ignorant or helpless, there will be ample opportunity

" Knopf, " Pulmonary Tuberculosis : Its Modern Propliylaxis and
the Treatment in Special Institutions and at Home". P. Blaluaton's
Son & Co., Philadelphia, ISllll.

for the little one playing on the floor to inhale the dust laden
with bacilli, coming from the pulverized and dried expecto-
ration. Like all children it will touch everything on or near
the floor and then put the fingers into the mouth. To con-
ceive of a more certain method of ingesting tuberculosis is
hardly possible. If the child's nails are not clean and closely
cut it will inoculate itself with tuberculous substances. This
method of infection happens quite often, particularly when
the child is suffering from eczematous or other skin troubles.
The result may be a local tuberculosis, or, perhaps, more
frequeutly a lymphatic infection. To relieve the itching
sensation produced by the irritating nasal secretions of a
coryza, the child will poke its fingers into its nose and we
may have there the starting point of a facial lupus. Older
children are exposed to the same causes of infection, though
perhaps in a lesser degree, when playing in public or private
playgrounds, kindergartens, etc. That the infection of a
child attending school from other tuberculous children of
the same class, or even from a consumptive teacher, is pos-
sible, we must admit, especially in schools where the hygienic
conditions are poor and where no sanitary supervision exists.

What remedies have we to suggest to counteract these mul-
tiple dangers to which children are exposed from the ever
present bacillus tuberculosis?

To assure a rigorous prophylaxis against tuberculosis from
the very earliest day of childhood I do not know of any better
plan than to have printed directions issued by the boards of
health, which should be in the hands of every physician and
midwife to give to the future mother, to the nurse or the
immediate members of the family. These instructions should
contain everything relating to prophylaxis, general cleanli-
ness, ventilation, nutrition, etc. The leaflets should be
printed in plain, comprehensible language.

While it is now the almost universal practice never to let
a child be nursed by a tuberculous mother, for the sake of
preserving the strength and the life of the mother, prohibit-
ing the tuberculous mother to become the nurse should also
find a reason in the interest of the child. A tuberculous
mother may transmit tuberculosis to the child through her
milk.

While separating a child from the tuberculous mother and
giving it the best hygienic and sanitary environments else-
where, would be the ideal way of solving the problem, it is
but rarely practicable. We must find means to protect a
child in its own home. To avoid the inhalation of tubercu-
losis the greatest care should be exercised on the part of par-
ents, relatives or friends with whom the child lives. The
well-known precautions concerning the tuberculous expecto-
ration, and also drop infection, that is to say, the ejection of
sm.all particles of bacilliferous saliva during the so-called dry
cough, loud talking or sneezing, should be rigorously adhered
to by everyone wlio may come in contact with the child.
The child should not sleep with a tuberculous mother. It
should have its own little bed from the day of its birth.
The child should never be taken on visits to consumptive
friends or relatives.

278

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

As a matter of course, if a child should be removed from
the pai-ents' home and be boarded elsewhere, one should be
sure that there is no consumptive in the new home of the
infant, and that it is not frequented by consumptives. Day
nurseries or infants' shelters where working women often
leave their infants shoidd be subject to thorough sanitary
supervision and no tuberculous individual should be employed
in such an establishment. In choosing a wetnurse or simple
attendant to a child one should always assure oneself of the
absolute health of the individual.

To combat the danger from ingestion of tuberculous cow's
milk is, of course, primarily a duty which devolves upon
sanitary authorities, the State, county, or city boards of
health respectively. It is the duty of these authorities to
make the sale of tuberculous milk practicably impossible.
But to all mothers who do not nurse their children it should
become a religious duty to boil or sterilize the child's milk,
particularly in cities where one is never certain of the abso-
lute purity of that article. Whenever it is possible cow's
milk should be replaced by goat's milk, which, as is well
known, is almost never tuberculous. \Vhen the child grows
older and cats meat, all that is of doubtful origin should, of
course, be thoroughly cooked.

To kiss the child on the mouth should not be allowed in
any case, and as the child grows older it should be taught
not to kiss strangers at all and relatives and friends only on
the cheek. Caressing and kissing domestic pets, such as
parrots, canary birds, dogs, cats, etc., should be discouraged.

Since we have spoken of the possibility of midwivcs or
physicians infecting the newborn child in the attempt to
bring its respiratory organs into play, we will also suggest a
remedy. To avoid such accidents the mouth-to-mouth re-
spiration should be replaced by the safer method of using
the catheter, as recommended by Tarnier and Lusk. La-
borde's method of rhythmical traction of the tongue will also
suffice to cause the child to breathe if the obstructing mucus
has been removed. A simple swab suffices to remove this
mucus, and to do this by mouth-to-mouth suction is to be
condemned.

The bottle and nipple through which the child receives
its milk should be kept scrupulously clean, and the tubercu-
lous mother should never put the nipple into her mouth.
Later on, when the infant is old enough to be fed with a
spoon she should again bear in mind that her own saliva is
likely to be bacilliferous and she should avoid using the same
spoon for herself and child. The remnants of food left by a
tuberculous invalid should not be eaten by any one, but more
particularly not by a child, neither should the latter eat any
food handled by a consumptive.

Inoculation of tuberculosis of an infant through the ortho-
dox rite of circumcision will be difficult to combat by a
simple protest against this operation on the part of physi-
cians, although it is well known that syphilis and diphtheria
have also been transmitted through this suction process, and
that through lack of skill in after treatnu-nt, secondary hem-
orrhage, erysipelas and gangrene having ensued, orthodox

Hebrews will rarely permit any modification in this proce-
dure. I would therefore suggest as a remedy that only such
persons should be allowed to perform circumcision as have
shown the necessary skill before a medical board of examin-
ers, and that every time they are called upon to perform the
rite they should submit themselves to a medical examination.
Only when bearing a certificate from a regular physician,
stating the absolute freedom from specific diseases, should
they be allowed to perform ritual circumcision.

As another reliable prophylactic measure against the pos-
sibility of inoculating the child when the parents insist upon
the orthodox method of circumcision, is the suction by the
aid of a glass tube, as practiced in France and Germany.

So much for the measures to protect the infant during his
earliest age from the possibility of infection in the three
ways, inhalation, ingestion, and inoculation. We will now
see what can be done in the line of prophylaxis for the child
who creeps on the floor, learns to walk, visits kindergartens,
plays on public or private playgrounds, visits menageries,
and finally goes to school.

The floor of the rooms where the child lives and on which
it plays should not be carpeted. It should be kept scrupu-
lously clean and, if desired, a clean mat may replace the
carpet. To keep the ordinary wooden floor clean and as far
as possible aseptic, the use of petroleum wax as recommended
by E. Petit " should be endorsed. Experiments have dem-
onstrated that the various pathogenic microbes, such as the
bacillus of diphtheria, of typhoid fever, the streptococci and
staphylococci, and the bacterium coli, can not live in this
substance, and the tubercle bacillus loses its virulence when
in contact with it. The cracks in the floors should be filled
and also covered with this substance. Water and even anti-
septic substances do not alter this wax. The ordinary broom
should never be used in cleaning children's rooms; if wiping
the fioor is not practicable it should be swept with moistened
sawdust. All these precautions recommended for the chil-
dren's rooms in the private home should, of course, be prac-
ticed if possible even with more rigor in public nurseries,
kindergartens, asylums, orphanages, etc.

In view of the possibility of infecting any room by drop
infection it is best that the consumptive, even if ordinarily
careful with his expectoration, should sojourn as little as pos-
sible in the children's rooms. Of course, it goes without
saying that neither spitting nor smoking should be allowed
in children's qiiarters. Expectorating on or near public or
private playgrounds should be considered a misdemeanor and
punished accordingly. These grounds should be kept spe-
cially clean and from time to time be strewn with clean
gravel.

The greatly loved visits of little ones to menageries must
be of concern to the sanitarian who desires to protect the
children from tuberculosis. To visit the ape house in the
zoological gardens and to remain there as long as possible is

'- " Recherclies siir un precede simple pour aseptiser les planchers,"
Congres de la Tuberculose, 1S98.

Septembeb, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

279

the delight of children, and yet, perhaps next to cattle there
are no animals so subject to tuberculosis as apes. Add to
this the commotion, dust, and impure air in the average
ape-house at the usual time of the children's visits, and one
cannot help thinking of an absolute danger. The managers
of menageries and zoological gardens should do their very
best to reduce this source of infection to the least possible
minimum. A tuberculous keeper might very easily infect
the animals under his care, especially since their confinement
makes them particularly susceptible to the invasion of the
bacilli. The law which authorizes the killing of tuberculous
cattle should be extended to all other animals as well. There
seems no reason why an ape house, containing numerous con-

sumptive animals, should not be as much a source of infec-
tion as a tenement house where ignorant or careless tuber-
culous individuals have expectorated indiscriminately. Ex-
pectorating on the floor or anywhere else in these menageries
should be strictly prohibited to keepers as well as to visitors,
and the floor should always be strewn with moistened sawdust
during visiting hours.

The hygiene which should prevail in the kindergarten
and playroom should, of course, also be universal in the
school-house. School children should be taught the use of
spittoons and handkerchiefs. Expectorating anywhere ex-
cept in a proper receptacle should be punished in the same
way as any violation of class rules. The elevated non-break-
able spittoon should be given preference to the ordinary por-
celain or glass cuspidor placed on the floor. I have often
wondered if the individual pocket flask in the public school
would not also tend to decrease epidemics of hiccoughs.

measles, and grippe, besides being one of the best means of
preventing the contraction of tuberciilosis through indis-
criminate expectoration. Each child should have a cupboard
where he should keep his own towel and drinking-cup. To
avoid drop infection, children should be taught to always
hold a handkerchief before their mouth while coughing or
sneezing.

Obligatory periodical disinfection of the schoolroom by
formaldehyde gas may also be advantageously instituted. To
make the disinfecting and cleansing of the classroom as thor-
ough as possible, I would suggest that desks and chairs be so
constructed that they can easily be folded together after
school hours. This innovation in school hygiene was first
inaugurated by School Superintendent Akbroit, of Odessa,
with most satisfactory results. As another sanitary measure
I would insist that lady school teachers and the grown-up girl
pupils should not under penalty of discharge, be allowed to
wear trailing dresses. The short rainy-day skirt is, in my
humble opinion, most becoming to teachers and pupils, and
certainly far more sanitary than the trailing skirt which so
often is made to do the scavenger's dirty work.

The fundamental principles of hygiene, especially in regard
to the prevention of tuberculosis, should be made part of the
curriculum in every class. I was told by Dr. Roger S. Tracy,
of the New York Board of Health, that there existed in some
town out west, the name of which he had forgotten, the
custom of inclosing a leaflet for the teaching of hygiene in
every book belonging to the school. Now, it seems to me
that this is an excellent idea and a good way to teach the
fundamental principles of general hygiene and particularly
the prevention of tuberculosis, and I would strongly recom-
mend this plan to all our boards of education.

Kissing, which is such a prevalent practice in some girls'
schools, should be discouraged and designated as unhygienic.
While children suffering simply from scrofulous manifesta-
tions might be permitted in public schools, all pupils suffer-
ing from pulmonary tuberculosis, or teachers afflicted with
the same disease should not be allowed there.

280

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

The early recognition of pulmonary tuberculosis, which
is so essential in the solution of the tuberculosis joroblem in
the adult, is equally important in regard to the combat of this
disease in childhood. Here comes a function of the school
physician (and no school should be without one) which, I
believe, has not as yet been sufficiently apfireciated nor ex-
ercised. The chest of every child attending the public school
and every teacher teaching there should be carefully examined
at least twice or three times a year, if owing to a large number
of pupils this can not be done every three months. Through
the early discovery of tuberculosis in a pupil, an immediate
warning to the parents, and timely and judicious treatment
many a young life will be saved.

To prevent an inoculation tuberculosis during the time the
child is likely to play on the floor, mothers and nurses should
see that the child's fingers are kept as clean as possible and
his nails cut. As long as the child is too small to clean its
nose, regular nasal toilets with some mild borated solution or
warm previously boiled water should be instituted. Eczemas
and other skin eruptions should receive immediate medical
attention, for, as has been said, left to themselves they may
give entrance to tuberculous infection.

We come now to the second portion of our discourse, which
treats of the hereditary disposition which the child of tuber-
culous parentage possesses at birth. We may define this
hereditary disposition in two ways. As bacteriologists wc
would probably say a hereditary predisposition is that pecu-
liar condition whereby the various organs, and in particular
the respiratory and next to it the intestinal tract, ofEer a
very favorable soil or culture medium for the development
and multiplication of the bacilli. As clinicians we might say
hereditary predisposition to tuberculosis means a physiolo-
gical poverty, brought as an inheritance into this world,
whereby the system is minus phagocytic and bactericidal
powers inherent in strong and healthy organisms.

It is well known that the transmission of a tuberculous
tendency comes most frequently from the maternal side.
The most radical means of preventing a progeny subject to
tuberculosis would, of course, be the interdiction of marriage
to all tuberculous individuals. Our present state of society
and our conception of individual liberty will scarcely make
it possible for the time being, to inaugurate legislative means
to counteract marriages between tuberculoiis individuals.
General education and enlightenment on this question may
be helpful as a prophylactic means, but the family physician
will have to do the bulk of the work in preventing such
dangerous unions. Even the cured consumptive should not
think of marrying until a considerable time after his com-
plete restoration to health. Gerhardt " counsels to wait
at least one year, but I consider this hardly enough and
would much rather make it two years.

To bring about abortion when a conception has taken
place in a tuberculous mother I consider useless. Instead of

" " Ueber Eheschliessunc;en Tuberkuloser," Zeitsclir. f. Tuberkulose
. Heilstattenwesen, September, 1900.

saving one life there is the danger of sacrificing two; but in
view of our present knowledge of tuberculosis I have no
liesitation to declare that I do not consider it a sin either
liefore God or man to instruct a tuberculous mother or father
that they may not procreate a tiiberculous issue. If, in spite
of the warning of the family physician, a tuberculous mother
has conceived, what are we to do? Shall we leave the mother
and child to their fate? Surely not! Though the mother
may be suffering from tuberculosis and the child seerningly
be doomed to become a candidate for consumption, modern
therapy has taught us not to despair, and we may save the
lives of both; but we must begin by treating the child in
iitero and with this, of course, begin a thorough treatment
of the mother's condition, and continue it at least a year after
confinement. A woman who is to give birth to a child
should abandon the corset and tight clothing in time to allow
a continued, free abdominal and thoracic respiration. Better
yet is it if she has never been addicted to the habit of tight
lacing, for the experiments of Kellogg " and Mays have dem-
onstrated that the so-called female or costal type of respira-
tion which prevails among civilized women is the result of
their restricting and unhygienic mode of dress, and is not
due to the influence of gestation or to a natural difference
in the anatomy and physiological growth of man and woman.
If a support for an unusually large breast must be worn let
the corset be replaced by a comfortable waist which permits
free and deep respiratory movements. Instead of tying her
skirts around the waist she should wear them suspended from
the shoulders. By wearing a close-fitting union-suit for un-
derwear of wool or cotton, according to the season, it will be
possible to get along with less skirts and thus lessen the weight
around the waist. In short, the whole dress of the mother
sliould be so arranged that there are no restrictions and that
no organ in the body should be hindered in its free physio-
logical functions. For the future mother to live as much as
]iossil)le in pure, fresh air, to take frequent breathing exer-
cises, to avoid crowded assemblies where the air is vitiated,
to live, in short, as hygienic a life as the family's social con-
dition will permit, will have a most salutary effect on the
child's health. If the circumstances are such that you can
induce this family with a tuberculous mother, living in the
city, to move to the country or to a smaller town where
modern hygienic conveniences can be had, but where the
crowded and noisy conditions of city life are absent, so much
the better for the prospects of mother and child.

The newborn babe is in need of pure, fresh air as much
as the mother; and the lying-in room and the nursery should
always be well ventilated. When in due time the child is
taken for an airing, the thick, almost impermeable veil should
be abandoned. These veils, often tightened around the
little face, press against the nose and make it difficult for the

''Kellogg, "Experimental Researches Respecting tlie Relation of
Dress to Pelvic Diseases of Women", Transactions of the Michigan
State Medical Society, 1888.

Septembee, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

281

child to breathe naturally, yet the mother wonders how the
baby got into the habit of breathing through the moiith.

Frequently also, mouth-breathing in children, and some-
times in adults, must be attributed to adenoid vegetation in
the nasopharynx, or to enlarged tonsils. Tliese as well as
all other causes of obstruction to a free, natural respiration,
such as deviated septum, enlarged turbinated bones, hyper-
trophied mucous membrane, polypi, etc., must be removed
if we desire to protect the child or adult from chronic nasal,
pharyngeal, or laryngeal catarrhs, so often the forerunners
of pulmonary disease.

The proper bringing up of children that have a tendency
to become Uilierciildus is of the greatest importance. Many
are poor eaters from the day of their birth. Discipline, not
to allow too many sweets, to observe regular meal-times, and
to keep the bowels in good condition, are the best means to
combat a dislike for eating. As early as possible children
should be taught to clean their teeth thoroughly after each
meal, for a good digestion is dependent upon the good state
of the teeth. The dislike to play outdoors, which is so char-
acteristic of the little candidates for tuberculous diseases, can
also only be overcome by discipline. To dress them too
warmly and bundle them i;p all the time is as injurious as
having them remain most of the time indoors. This harden-
ing of the constitution will be the best method to counteract
a disposition to take cold easily, which in children predisposed
to tuberculosis has often a tendency to develop catarrhs of
the deeper respiratory tract.

I consider the air-bath and sun-bath for children at the
earliest age most beneficial. Let the little ones toddle around
naked every day for a short time; in cold weather in well-
warmed rooms, and in summer in a room bathed by the rays
of the sun, but always on a clean floor or clean Japanese mat-
ting. With their growing intelligence children should be
taught by practice and example the value and the love of
pure, fresh air. As soon as the age and intelligence of the
child will permit, breathing exercises should be taught him.
He should learn to like them as the average child does gen-
eral gymnastics.

The lying-in room, the nurseries and playrooms must
always be well ventilated. Public as well as private schools
and colleges should be model houses in regard to cleanliness,
hygiene and constant ventilation. Ventilation not only
when the children have left, but all the time, and, as Emmert''
says, since windows and doors alone do not suffice to properly
ventilate rooms when occupied by a mass of human beings,
mechanical devices should be resorted to to secure always
a plentiful supply of fresh air. Overwork during school
life is an indirect cause of furthering a tuberculous tendency
in many children, and indeed it is injurious even to a healthy
child. Much out-door play, singing and reciting in the open
air should be encouraged. This life out of doors, the love for
pure and fresh air, for gymnastics and out-door sports should

'* Emmert, "Is Our Public School System Conducive to Tuber-
culosis?" Transactions of the Iowa State Med. Society, 1808.

be kept up by the young man and girl leaving school through-
out life.

In choosing his future career the young man born with
that peculiar susceptibility which Peter describes so aptly as
" tubeirulisable " should seek professions which will demand
out-door life. Farming, gardening and forestry will assure
him the longest and most useful existence.

Hydrotherapeutics, as a measure to prevent pulmonary tu-
berculosis, tends to develop to more vigorous action the vaso-
motor system; it also should be instituted at an early age.
A child, a few months old, can support with impunity a
rapid sponging off with cold water after its warm bath, fol-
lowed by a relatively vigorous friction with a soft Turkish
towel. As the child grows older he should not only be taught
this use of cold water after his semi-weekly or weekly warm
bath, but he should wash at least the face, neck and chest
every morning with cold water. Better yet, if he can accus-
tom himself early to a daily cold douche. The utility of all-
the-year-round swimming baths, where old and young of all
classes can, gratuitously or for a moderate price, enjoy the
salutary effects on body and mind of a good swim, is too well
known to need to be insisted on.

There should be many small parks and playgrounds and
pulilic baths for old and young in the densely crowded dis-
tricts of our large cities. City parks have Justly been called
the lungs of great centers of population. Here mothers and
children of the poor can breathe purer and fresher air, which
is one of the best means of preventing tubercidosis.

I have thus far but slightly touched on the sociological
side of prophylaxis. I have not made much distinction
between scrofulous and tuberculous diseases, for the former
is but a lighter form of tuberculosis. The same sociological
conditions which further tubercidosis in the pulmonary form
further also scrofulous diseases. Children from syphilitic
and alcoholic parents arc particularly prone to tuberculous
and scrofulous affections. In seeking to prevent tubercu-
lous and scrofulous diseases in childhood we must combat
our two great social evils, syphilis and alcoholism.

Here I cannot help also denouncing strongly the employ-
ment of children under fourteen years of age in various
industries requiring often six to ten hours of continued
manual labor, and often in factories and mines where work
even taxes the healthy organs of a full-grown man.

Of tlie frequency of scrofulous and tuberculous troubles
among children of the poor one has scarcely an idea. In
one of the public schools of Berlin, where careful statistics
are kept concerning the daily attendance of the children,
it was found that out of 125 boys and 133 girls who did not
attend school regularly, not less than 112 of the former and
115 of the latter suffered from tuberculous or scrofulous
troubles. As to what is best to do for the underfed pupils,
the children of poor parents, attending our public schools,
I would suggest a philanthropic enterprise which would cost
little and which would do a world of good. Provide them
with a lunch of a few good meat sandwiches and one or
two fflasses of good milk, and I am convinced that fewer

282

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 136.

will develop tuberculosis and scrofulosis, and they will do
better work at school and at home. A similar experiment
has been tried recently in one of the German schools for the
poor, and the results have been most gratifying; nearly every-
one of the children gained in weight and strength in a rela-
tively short time.

For children suffering from either tuberculous or scrofu-
lous manifestations the treatment is well known. Codliver
oil, arsenic, iron, but above all hygienic and dietetic meas-
ures, aero-, hydro- and solar therapy, under constant medical
supervision in a good healthy locality, preferably in sanatoria
erected for that purpose in the country or on the seashore,
have proven to be the most efficacious means to treat these
diseases during childhood. With so many beautiful places
in our inland and seacoast towns, which would be suitable
for children's sanatoria, it is to be regretted that we have
almost no such institutions as yet. In France, Germany,
Holland and Italy there exist numerous children's sanatoria
for the treatment of tuberculous and scrofulous diseases. To
these are attached splendid schools so that the intellectual
side of the children's training is not neglected. The results
obtained in these institutions for the little sufferers are even
better than those for adults, the latest reports giving as much
as 50 to 75;^ of complete cures.

Under medical news from Colorado I read in last week's
Journal of the American Medical Association (May 18th),
that by order of State Health Commissioner Clough, promul-
gated April 15th, sufferers from tuberculosis are exchided
from public schools. This moans, of course, an exclusion
of tuberculous pupils and teachers alike. But, I ask, has

the State of Colorado provided another place of instruction
for these little ones? Is it Just to exclude a child from public
school for so long a time as the cure of such a chronic disease
as tuberculosis must of necessity require? The action of any
health authority in suppressing tuberculosis in public schools
should be commended, but before enforcing the regulations
which deprive the child of the right and privilege of educa-
tion, those authorities should see that specially constructed
sanatoria-schools should be erected where these little ones
receive not only the benefit of judicious medical treatment
and practical hygienic training, but also that school education
to which evexy American child is entitled.

There is a strong awakening now for the need of sanatoria
for consumptive adults throughout the United States. Let
us in our eagerness to treat the consumptive man and woman
not forget that to treat tuberculous and scrofulous children
is just as important. These special children's sanatoria, situ-
ated on the seacoast or inland in particularly healtliy locali-
ties, are powerful agents in the prevention and cure of tuber-
cidosis. By carrying out the prophylactic measures which I
endeavored to outline in the first portion of my lecture and
by providing institutions for children already afflicted with
tuberculous or scrofulous diseases, we will prevent many a
one from becoming a consumptive man or woman. Through
jDrevention and timely cure these little ones have many chances
to become strong, healthy and useful members of the com-
munity. Let us take good care of the little children and
never forget that the child of to-day will be the man of to-
morrow.

16 West Ninety-Fifth Street.

RESPIRATORY EXERCISES IN THE PREVENTION AND TREATMENT OF PULMONARY

DISEASES/

By S. a. Knopf, M. D., New York City.

I have chosen this subject for the second lecture which I
have the honor to deliver before you, in the hope that it
may result in some practical good, not only to your patients,
but also to yourselves. We as physicians are very apt to
neglect our own health. Often deeply absorbed in our work
we forget, for example, to take our meals regularly; or we
eat hastily, and do not rest when we ought to rest. The
general practitioner, and the majority of us are general prac-
titioners, is the greatest sinner in this respect. We will
often scold the members of the families, whose physicians
we may be, if we discover them to be neglectful in these
matters so essential to a healthful life, and still every day
we are doing the very things which we tell them not to do.

I believe this is a good opportunity to sound a note of
warning. I have the honor of addressing physicians older

' Lecture delivered before the Senior and Post-graduate Classes of
Johns Hopkins Medical School, May 29, 1901.

than myself, some of my age, and some a good deal younger.
Of the older ones I must ask pardon for trying to teach them
what they know better than I, but what I know they only
teach to others and rarely practice themselves. These, my
seniors, I will only remind what a good thing it would be
fo'r their own welfare to practice as regularly as possible
what they preach so frequently. To my colleagues and
younger friends I will say, preach regular living to your
patients and practice it yourselves. As a rule take your
meals regularly, irregularly only as an exception. Take time
for your meals and only eat hastily when it must be done.
Never start out to work with an empty stomach. Get eight
to nine hours sleep out of every twenfy-four; if not po.ssible
to have it in one stretch, take this time, necessary for recu-
peration, in installments. Eight liours of sleep, regular
meals, good nutrition, good digestion, and proper assimilation
of our food are, however, not more important to our well-
being and that of our patients than good air and proper

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

283

breathing. The natural man breathes physiologically; but
civilization with the many blessings it has conferred iipon
ns has also brought to lis certain customs in the shape of
dress, habitation, and occupation, which interfere with the
natural process of breathing, on one hand by restricting our
thoracic and abdominal organs by uncomfortable dress or
peculiar posture, and on the other by placing us in environ-
ments which make it impossible for us to get constantly a
sufficient amount of fresh, pure air.

Let us first try to define what natural breathing is. While
air may enter the respiratory tract of man through the
mouth when he is speaking, for the greater part of his ex-
istence he should breathe through the nose. The nose is
the natural organ for the entrance of air. Its osseous con-
formation and its lining, the Schneiderian membrane, have
the function to protect the deeper respiratory tract from
foreign and irritating substances, and to render the cold air
inspired warm enough not to be injurious to the delicate
pulmonary structure. The first requisite then for good
natural breathing is a nose free from all obstructions. Spurs,
a deviated septum, polypi, or a marked hypertrophy of the
mucous membrane, adenoid vegetations, in short, whatever
prevent the air from, passing freely through the upper respi-
ratory tract, are a hindrance to the natural respiratory pro-
cess. Only by removing these hindrances can we hope to
get the benefit of a natural respiration.

Of the value of right physiological breathing in the pre-
vention of disease, it is not necessary to dwell at length
before an audience of physicians and advanced students in
medicine, but I hope that I may not hurt the feelings of any-
body in this amphitheater when I say that in order to im-
press upon your patient the importance of natural physiolo-
gical breatliing you must practice it yourselves. My main
object to-night is to show the value of special breathing ex-
ercises in the development of the child, in the prevention of
pulmonary diseases, particularly of consumption, and to de-
scribe and demonstrate some exercises which seem to me
particularly useful in phthisiotherapy and the treatment of
some other pulmonary affections.

After having assured yourselves that there is no obstruc-
tion in the upper respiratory tract to the free entrance of
air, the next most important step is to see that the clothing
of the individual to whom you intend to teach breathing
exercises, whether he be man, woman or child, does not con-
strict cither throat, thorax or abdomen. The man or woman
with a high or tight collar or other neckwear constricting
the throat, cannot possibly breathe deeply nor correctly. Not
only women but men also at times have the clothing too tight
around the chest to permit a free expansion of the thorax.
Some men think they can breathe better by wearing belts
to hold their trousers. I do not approve of wearing belts
for that purpose; it does not facilitate breathing and inter-
feres with the peristaltic action of the intestines, and it may
even bo the cause of the development of a hernia. While
the man perhaps will acknowledge that he is uncomfortably
dressed when you so tell him or that the belt, if he wears

one, is too tight, a woman will but rarely do so. If she wears
a corset she will assure you that it is not at all tightly laced
and that there are really no constricting bands around her
waist. You must exert all posible tact to convince her of
this error, for I believe I do not exaggerate when I say that
a large majority of women wearing corsets wear them alto-
gether too tight. Some women must wear a support of some
kind, but many of them could get along very well without
one, and none need a tightly laced corset, nor need they
fasten their skirts in such a way as to constrict the abdomen.
If they only would develop their thoracic muscles they would
have a natural and more graceful carriage than the one ob-
tained by that little instrument of torture, called the corset.
Whenever a support is indispensable let women wear a corset-
waist without steel-bones. Skirts should be worn in such a
manner that the weight is carried by the shoulders.

A good way to convince your pupil or patient that un-
comfortable and restricting garments do not permit free ex-
pansion of the chest is as follows: Tell him or her to stand
in the morning before dressing and in the evening before
retiring, stripped to the waist, in front of the looking glass
and there take the breathing exercises which we will describe
presently. The pupils or patients will thus realize the dif-
ference between breathing with or without restricting gar-
ments. They will watch their respiratory muscles develop-
ing, and become intensely interested in these lung gymnas-
tics. The exposure of the chest to the air for a few minutes
every morning and evening has an additional advantage.
The skin which is also a respiratory organ receives a health-
ful stimulation through this exposure to the cool air. I
venture even to say that this air-bath of throat and chest,
when regularly practiced, will have a most beneficent influ-
ence in the prevention of colds.

Presuming then that you have satisfied yourselves that the
pupil to whom you are to teach respiratory exercises is dressed
in such a manner that there remains not the slightest re-
striction around throat, thorax or abdomen, you can begin
your instructions. It goes, of course, without saying, that
you should teach the breathing exercises always either in the
open air or in a well ventilated room, preferably in front of
an open window. A locality where the individual, by taking
deep breaths, would only inhale an additional amount of
impure odors or dust, is, of course, not suitable as a place
for teaching breathing exercises. Starting out with the pre-
sumption that we find ourselves in suitable environment for
respiratory gymnastics we teach our pupil to assume the posi-
tion of the military " attention " — heels together, body erect,
chest forward, head straight, the palms of the hands touch-
ing the external portion of the thigh. We tell the pupil to
keep his mouth closed and to take a slow deep inspiration
through the nose, that is to say, taking in all the air possible
with one inspiratory movement, to hold his breath a few
seconds, and then exhale just a trifle faster. If the pupil has
done this act well, we supplement it by allowing him to raise
the arms to a horizontal position. He does this during the
act of inspiration, remains in that position for a few seconds

284

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 12G.

and while exhaling brings the ai-ms down to the original
position. The act of expiration should again be a little
more rapid than that of inspiration.

When the first exercise (Fig. 1) is thoroughly mastered
after a few days, the pupil can be taught a second one, which
is like the first except that the upward movement of the
arms is continued until the hands meet over the head (Fig.
1). The third respiratory exercise, somewhat more difficult
and requiring more strength and endurance, should not be
imdertaken until the first two have been mastered and prac-
ticed for several days. The third exercise might justly be
called a dry swim; one takes the same military position of
"attention," heels together, body erect, and then stretches
out the arms as in the act of swimming, the dorsal surfaces

/h.

Fig. 1. — First and Second Breathing ExerciBes.

of the hands touching each other. He then moves the arms,
just as if he was dividing the water, during the act of inspir-
ation, the hands meeting finally behind the back. The pupil
remains in this position for a few seconds, retains the air,
and during exlialation brings the arms forward. This some-
what difiicult exercise can be facilitated and made more effec-
tive by rising on the toes during the act of inspiration and
descending during the act of expiration (Fig. 2.)

Valuable as these exercises with the moving of the arms
are, they cannot be practiced everywhere and at all times
without attracting attention. Under such conditions one
must often content oneself with raising the shoulders, mak-
ing a rotary movement backward during the act of inhala-
tion, remain in this position, holding the breath for a few
seconds and then exhale while moving the shoulders forward
and downward, assuming again the normal position. This

exercise (Fig. 3) can even be taken while walking and, of
course, very easily while sitting or riding in the open air.

Young girls and boys, and especially those who are pre-
disposed to consumption, often acquire a habit of stooping.
To overcome this the following exercise is to be recom-
mended. The child makes his best effort to stand straight,
places his hands on his hips with the thumbs in front, and
then bends slowly backward as far as he can during the act
of inhaling. He remains in this position for a few seconds,
while holding the breath, and then rises again somewhat
more rapidly, during the act of exhalation (Fig. 4).

Concerning the general directions as to the frequency and
order of these exercises I can only say here the same that
I have said in previous writings when speaking of aerothera-

FiG. 2. — Tliird Breathing Exercise.

peuties proper: Commence always with the easier exercises
and only gradually take the more difficult ones. Eepeat the
exercises from six to nine times either of one kind or the
other, every half hour or so, or three of each, and continue
this practice until deep breathing has become a natural
habit. One rule which is applicable as well to the pupil
whom you teach to breathe to prevent disease as to the
patient for whom you prescribe respiratory exercises as a
means of cure, is the following: Instruct them never to
take the exercises when tired and never to continue them
so long as to become tired.

Before we proceed to discuss the specific respiratory exer-
cises suitable in diseases, let us also say a few words of the
value of speaking, reciting and singing in the open air, or
at least in well ventilated rooms or halls. To my mind
there is not enough done in the physical education of our

SeptembeKj 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

285

children in this respect. Cases of phthisis wliich had even
passed the incipient stage have been recorded as cured in
individuals who, after realizing their condition, decided to
follow the occupation of street singer or speaker. I know
of the case of an English lady who became an evangelist
addressing crowds of people every night in open air meetings
and who actually was cured from her tuberculous disease
after following this calling for a year. Barth, of Koslin,
who has made a careful study of the effects of singing on
the action of the lungs and heart, on diseases of the heart,
on the pulmonary circulation, on the blood, the vocal appa-
ratus, the upper air passages, the ear, the general health, the
development of the chest, on metabolism, and on the activity
of the digestive organs, has come to the conclusion that sing-

FiG. 3. — Breatbiug Exercise
with Rolling of Shoulders.

Fig. i. — Exercise for People
in the Habit of Stooping.

ing is one of the exercises most conducive to health. Con-
sidering the fact that it can be practiced anywhere (when the
air is pure) or at any time, without apparatus, it should be
much more cultivated than it actually is. The German
military authorities, who have the reputation of instituting
all exercises which tend to invigorate the soldiers, have of
late years encouraged singing by the troops during marches.
We will now speak of respiratory exercises in their thera-
peutical aspect in various pulmonary diseases. The six path-
ological conditions of the respiratory system which may be
very greatly helped by proper judicious breathing exercises,
are bronchitis, asthma, emphysema, an inactive lung owing
to a badly resolved or slowly resolving pneumonia, deficient
breatliing owing to pleuritic adhesion, the remainder of an
inflammation of the pleura, or convalescent emphysema, and
last but not least, pulmonary tuberculosis.

In ordinary bronchitis, after the acute febrile state has
passed, the exercises taught above for the development of a
good breatliing capacity in children, will answer for all prac-
tical purposes. These deep inspirations and expirations will
be particularly useful in dissolving the mucus and making
the expectoration easier. Except in simple bronchitis or
badly resolved pneumonia you will probably find in tlie
affections, just enumerated, if not a deficient development,
a more or less pronounced atrophy or inactivity of the ab-
dominal and thoracic muscles which should come into play
in deep natural breathing. There is no use in teaching or
prescribing respiratory exercises if the muscles which are to
perform these exercises are lazy, badly developed or atro-
phied.

How are we to overcome such an atrophy in an emphy-
sematous, asthmatic or phthisical patient? Electricity and
massage are, of course, the best remedies. The most im-
portant of the two, and the one which I prefer, is certainly
a proper, skillful and regular massage of the abdominal and
thoracic muscles. While I do not expect every physician
to massage his own cases, it seems to me equally unwise
to leave the work entirely to the masseur, masseuse or nurse
and content ourselves with telling these, our assistants,
simply to massage the patient. We should certainly know
ourselves how to do this massage and how to give instruc-
tion in this important physical method of curing disease.

Allow me to describe here and to demonstrate before you
the method of massaging a patient with badly developed
abdominal and thoracic muscles, which has given me the
most satisfactory results. I place the patient on a moder-
ately high table or bed with no springs. The height of th(
bed or table should be suited to the height of the operator.
The latter must be able to bend comfortably over the patient
and exert a moderate amount of force without getting too
tired himself. A low bed with spring can not be used for
applying scientific massage.

The room in which the patient is to be massaged should
be comfortably warm and always well ventilated. To avoid
unnecessary exposure it is well to have a shawl handy so as
to protect that portion of the patient which is not manipu-
lated at the time. Whether or not to use vaseline or some
other substance for the purpose of lubrication will largely
depend upon the masseur or patient. As a rule lubricants
are not essential; of course there are cases of tuberculosis,
and especially in children, where the use of codliver oil for
this purpose may be very advisable.

The four movements which I employ are the following:
friction, kneading, tapping and pinching. In the friction
movement, and as much as possible in all the others, I like to
follow the course of the venous circulation; in abdominal
massage I like to bear in mind the situation of the colon,
and thus at the same time aid in overcoming a tendency to
constipation. This is done by massaging the colon separ-
ately, following its course along the ascending, transverse
and descending portion. Around the umbilicus a circular
motion from right to left is the best to be employed. This

286

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

massage of tlio abdominal wall should be more gentle than
that of any other portion of the body and should be supple-
mented by teaching the patient to retract and relax his dia-
phragm alternately, holding it for several seconds in the
retracted position so as to strengthen all the abdominal
muscles. This exercise of diaphragm and abdominal muscles
should be taught first to the patient in the recumbent posi-
tion; later on he should learn to make this movement also
in the standing posture. The massage which has the piirpose
of overcoming an atrophy of the respiratory muscles so that
the act of respiration should be more complete, must not in
the pidnionary invalid, and particidarly in one suffering from
chronic tuberculosis, be confined to abdomen and thorax
alone, but must include the arms and shoulders as well.

Here is what I believe to be the most convenient method
to massage the anterior muscles of forearms, arms, shoulders
and thorax. Begin your friction at the tips of the fingers
going as far as to the wrist articulation, from there to elbow
joints, from elbow to shoulder. By a semi-circular move-
ment, with moderately spread fingers and the palms of the
hands, try to take in by your friction movement as much
as possible of the posterior and lateral portion of the thorax.

After a few minutes of friction begin your true massage,
that is to say, kneading, from the French masser, to knead.
Manipulate the muscles so as to lift them from the osseous
attachment and in the same order as the friction movement.
The third movement is the tapping, which may be done with
the whole hand, the palmar surface of the four fingers, or if
desirable to avoid the clapping sound produced by this move-
ment, tap with the ulnar surface of your hand, producing a
sort of chopping movement.

The foin-th movement I recommend is pinching, of which
the particular purpose is to massage the skin. Pinch rapidly
the various portions of the skin which you have already
manipulated by friction, kneading and tapping. This pinch-
ing is most conveniently done, with least pain to the patient,
by lifting a small portion of the skin between the thumb and
the index and middle finger.

You now turn the patient on his chest with either the
right or left cheek resting on a pillow so that he can breathe
easily, while you manipulate the posterior muscles of arms,
forearms, etc. in the same order as you did the anterior por-
tion. If you are tall and vigorous and the patient not larger
than you, it is possible to apply the friction movement to
both arms, both shoulders and right and left portion of the
thorax at the same time. This is done by placing the palms
of your hands on the posterior portion of the patient's hands
and then apply a good friction movement over hands, fore-
arms, arms, shoulders and the posterior portion of the pa-
tient's thorax. The kneading, tapping and pinching move-
ments are, of course, the same as for the anterior portion
with the only difference that the posterior muscles of the
trunk will stand a more vigorous massage than the anterior
ones. The time occupied for anterior and posterior thoracic
massage should be about thirty to forty minutes.

An exercise which the patient may be taught while in bed

and wliich will add to the good effect of the massage is the
following: Tlie patient lies on his back with a small pillow
placed under him at about the height of the kidneys, so as to
lift up tlio thorax. lie then raises the arms in the air above
his head so as to describe a half circle with them. He can,
while raising the arms, take a deep inhalation, hold the breath
for a moment, and return them to the original position during
the act of exhalation, thus adding by active movement to the
good effect of the massage. Should your patient be a child
your ingenuity will probably be taxed at times in overcoming
the thoracic malformation. You will have to resort to some
special gymnastics, which, according to the indications, may
even have to be aided by a special apparatus for exercising
or by orthopedic appliances. The combination of all these
means to correct a thoracic malformation is, however, most
gratifying in these young children, and I am convinced that
if more attention would be paid to the correction of those
malformations which prevent the child's lungs from freely
expanding, there would be fewer cases of tuberculosis in adult
life.

Returning to our adult patient, and presuming that his
more or less pronounced atrophy of the respiratory muscles
has improved sufficiently imder this massage, we will proceed
to show what can be done in the various pathological con-
ditions of the lungs through special and judicious respiratory
exercise. Emphysema and asthma require a particular kind
of respiratory exercise. While, as a general rule in respira-
tory therapeutics, the act of expiration should always be
somewhat shorter than the act of inspiration, in these two
diseases we must rather try to prolong the expiratory act.
Having by our massage improved the thoracic muscles and
the often very flabby condition of the abdominal walls of
such an invalid, w-e tell him to bring all his respiratory mus-
cles into play during the expiratory act. He inhales quietly
through the nose as in ordinary inspiration, but we teach
him to exhale with his mouth open and place the palms of
his hands on his chest, the thumbs directly toward the axil-
lary region, and then exert a strong pressure on his thorax.
Through this exercise we endeavor to produce a long con-
tinued exhalation. Another valuable aid in recovering the
lost tonicity of the pulmonary tissue through respiratory
gymnastics is the following exercise which is particularly
useful because it can be done without attracting attention,
since the pressure with the hands on the thorax, while a
valuable help is not alwa}'s essential nor practical. The
patient is told to inhale ordinarily, but during the act of ex-
haling to place his lips as if about to whistle and then pro-
duce a blowing sound as long as he can without taking an-
other breath. We have him repeat this quite a number of
times a day, but always according to our formula — never
when he is tired and never to the extend of getting tired.
The improvement in the condition of many asthmatic and
emphysematous patients through such exercises is simply
surprising, and while I, of course, would not wish to under-
estimate any other hygienic, dietetic or medicinal treatment
in the various forms of asthma or emphysema, I do claim

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

287

that these exercises are most valuable adjuvants in the ther-
apeutic management of such invalids.

We now come to such exercises as I would advise with
judicious gradation in number and kind in conditions where
either through a badly resolved pneumonia, old pleuritic
adhesions, tuberculous deposits, or infiltration there is no
longer a proper physiological breathing and suflRcient haema-
tosis. The exercises I am to describe I have, of course, most
frequently employed with my tuberculous patients; but, valu-
able as they are, I wish to speak first to you of the contra-
indications, for respiratory exercises in pulmonary tubercu-
losis, or any other affection of the lungs, must not be blindly
prescribed. A patient in a highly febrile state, or during
an acute exacerbation of the tuberculous process, or an ac-
tive hemorrhage, should refrain from all respiratory exer-
cises. Following a haemoptysis all respiratory exercises with
movements of arms should be prohibited, at least for a time.
On the other hand I encourage quiet and deep respiratory
movements, a few at the time, following a haemoptysis. In
cases where the sanguine expectoration has continued for
weeks these deep, quiet respirations seem to have acted as a
veritable styptic. Irritating cough resulting from the at-
tempt to carry out the breathing exercises, or pleuritic pains
resulting from the tearing of old adhesions, are no contra-
indications to the continuation of the respiratory exercises.
Both cough and pain will cease in a short time. As long
as the patient has learned to breathe properly through the
nose and the air is relatively pure, cold, warmth, rain, snow
and even wind should not prevent the patient from carrying
out the physician's instructions for breathing exercises.

At times there are cases in which you desire to direct your
respiratory exercises, so as to develop more particularly either
the right or left lung. Under such conditions I have been
in the habit of temporarily strapping the healthy side of the
chest with the aid of adhesive plaster. Since coming to Bal-
timore my attention has been called to a much simpler and
equally efficacious method, namely that of Naunym. I take
the liberty to demonstrate this exercise before you, and take
particular pleasure in doing so, for I am indebted for this
acquisition of knowledge to your distinguished teacher. Pro-
fessor Osier. He showed me that by sitting in an ordinary
chair, with the healthy side of the chest pressing against the
back of this chair, one could almost immobilize temporarily
the healthy side, and by a deep respiration inflate the oppo-
site lung to a much greater extent than would be possible
without this fixation. Prof. Osier told me of what good
service this method had been in patients convalescent from
an empyema. I have been experimenting since in my room
at the hotel and have learned that all chairs are not suitable
for this excellent exercise. A chair with a concave back is
utterly useless for that purpose. Naunym's breathing exer-
cises for developing the right or left lung separately can best
be carried out with an ordinary chair, with a seat low enough
for the patient to fix his feet solidly on the floor. The back
should be straight or moderately convex, and low enough to
enable the patient to fix the top of it in his axilla, putting

his arm over the back and taking a firm hold of the seat from
the outside. All the other directions for proper breathing,
such as closed mouth, head erect, unrestricting clothing, are
of course as important for this exercise as for any other. A
second expiratory effort which we will describe presently
may also be added to enhance the good effects of Naunym's
exercises.

In all chronic forms of tuberculosis I have found the above
described ordinary respiratory exercises of the greatest value.
To increase their efficiency I have added a few movements
to my armamentarium. While we need not be over-careful
and over-precise when teaching respiratory exercises to a rela-
tively healthy child, or young man or woman, in order to
develop the chest capacity and respiratory function in the
tuberculous patient we cannot be too careful in this matter.
Not only the consumptive's physical but also his psychic
condition demands that our prescriptions for respiratory ex-
ercises should be considered as important as the administra-
tion of any medicinal substance. In the modern teachings
of phthisiotherapy air, air, and air again holds the first place,
and to utilize as much as possible of this valuable substance
we must not only have our consumptive patients live out-
doors all day, resting either on a reclining chair or exercising
by judiciously gradated walks, and at night have him sleep
with the window wide open, but we must also see that he gets
as much as possible of the good, fresh air into his lungs. I
therefore add to the ordinary exercises an additional move-
ment by having each respiratory act, that is to say, after a
deep inspiration and corresponding expiration, followed by
a second forced expiratory effort. This is for the purpose of
expelling as much of the supplemental air as possible, which
may be effectually aided by supinating the arms and pressing
the thorax with them.

Considering that the amount of tidal air — that is to say,
the volume which is inspired and expired in quiet respiration
— is only 500 cc, the complemental air — the volume which
can be inspired after an ordinary respiration — 1500 cc,
and the supplemental or reserve air — the amount which can
be forcibly expelled after an ordinary respiration — amounts
to 1240 to 1800 cc, one can readily see the value not only
of deep breathing, but particularly of this second expiratory
effort.

I may, perhaps, be permitted here incidentally to make a
few remarks on the deficient respiratory function of the
apices. The fact that in the majority of cases the tubercu-
lous process begins at the apices has been explained by the
supposed bad inspiratory function of this part of the lungs.
Now, I agree in this respect with Ilanau,' and consider the
almost universally adopted statement of the deficient inspir-
atory function of the apices erroneous. On the contrary,
those portions of the lungs inspire excellently well, almost
too well, for dust and all sorts of micro-organisms enter there
most easily and are found in large quantities in careful post-

^Hanau, A., Ziirlch, " Beitriige zur Pathologie der Luugenkrank-
heiten." (Zeitschr. f. kliu. Medicin, xii, 1887).

288

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 136.

mortem examinations. What is faulty is tlie expiratory
function of the apices. A thorough expiration followed by
a forced expiratory effort, as just described, is, to my mind,
the only possible way to improve this defect and prevent
stagnation and congestion, which, as is well known, form ex-
cellent media for the development of bacilli.

I will lastly demonstrate before you systematically the
four or six exercises which I prescribe to my tuberculous
patients according to their condition. To exercise No. 1.
which for pedagogic purposes consists simply in raising the
arms to the horizontal during the act of inspiration and to
lower the arms during the act of expiration, I add the fol-
lowing: I instruct the patient, while his arms are stretched
out in the horizontal position, to count three silently and
slowly by moving the hands up and down, and then lower the
arms during the act of expiration. Following this without
inhaling again, he makes a second expiratory effort, as de-
scribed. This second expiratory effort is not easy to teach
and some patients are not able to learn it at all. Why, I
cannot tell, but I usually succeed, at least in a measure, by
having the patient say the word " inch," prolonging the
vowel during the attempted second expiratory effort. To
the second ordinary exercise, where the patient raises his
arms above his head, I add a bending backwards of head and
thorax while the patient retains the air. This bending back-
ward and coming back to the original position requires about
five seconds; and the exercise is again followed by the second

riding, should also be followed, whenever

This is an equally

expiratory effort. This exercise will also tend to overcome
the habit of stooping. The third or swimming exercise,
which you can only use for the tuberculous patient nearing
recovery, may also be made more efficacious by a good vigor-
ous second expiratory effort. The fourth respiratory exer-
cise with rolling the shoulders which, as has been said, can
be taken without attracting attention on the reclining chair,
while walking or

possible, by a second expiratory effort
good exercise for patients in bed.

In teaching these breathing exercises I have not attempted
to classify abdominal and thoracic breathing. For individu-
als predisposed to tuberculosis, consumptives and other bad
breathers, abdominal and thoracic breathing should be com-
bined to assure the greatest possible play and expansion of
the limgs.

The value of respiratory exercises is now conceded by all
phthisio-therapeutists. To assure a good, complete hsema-
tosis, that is to say, as nearly as possible a perfect oxygen-
ation of the blood, to relieve the congested lungs of mucus
and facilitate expectoration, diminish inflammatory exudates,
in short, improve the respiratory and circulatory processes in
the tuberculous patients, or those suffering from similar dis-
eases, I know of no better means than judicious and regular
breathing exercises under the supervision of a well trained
physician.

16 West Ninety-fifth Street.

PULMONARY TUBERCULOSIS IN BALTIMORE/

By H. AVarren Buckler, M. D.

A study of the mortality records of any of our large cities
shows Pulmonary Tuberculosis or Consumption to be the
most prevalent as well as the most fatal disease existing to-day.
It causes about one death to every ten, and its victims average
between the ages of 15 and 60, the best periods of one's life.
With the exception of pneumonia and cholera infantum
phthisis causes more deaths per annum than any other three
diseases with which man is afflicted. During the past
twenty-five years, from 1875 to 1900, there have been in
Baltimore more than 28,479 deaths from phthisis, to say
nothing of the deaths due to other forms of tuberculosis.
The total mortality for the same period has been 222,562,
making a ratio of 12.8^. During the past five years the
death rate has been a trifle lower, owing no doubt to the
greater ease with which we are able to recognize the disease,
and to arrest its progress in its incipient stage. By years
the rate is as follows:

Year.

1895 .

1896 .

1897 .

1898 .

1899 .

Phthisis.

Total Mortality.

Pereeuta

1.141

10,301

11. %

1.222

9,919

11.3

1.047

9,329

11.2

1.061

10,385

10.2

.974

10,153

9.6

'Read before The Laennec, a Society for the Study of ruberculosis,
January 30, 1901.

Of the 10,700 persons who died last year in this city, 1050
were victims of pulmonary tuberculosis, whereas scarlet fever,
diphtheria and typhoid fever, three diseases usually dreaded,
were together accountable for only 490 deaths. A compari-
son of the death rate of Baltimore witli those of a few of
our principal cities is not at all unfavorable, especially when
one considers our large negro population, among whom the
disease is especially fatal. The following chart, made from
the tables of vital statistics of the several cities, shows the
number of deaths, resulting from phthisis during the past
year with its relative percentage to the total mortality.

Name of City.

Baltimore

New York

Philadelphia

Chicago

Boston

Dist. of Columbia.

Total Mortality. Phthisis.

10,700
70,873
2.5,078
21,809
11,154
6,026

10.56
8.155
2.717
3.514
1.289
.758

Percentage.

11.5
10.8
11.3
11.5
12.5

The above will show that Baltimore, even with its 80,000
or more negroes, is not the hotbed of tuberculosis as many
would believe, and when we consider that for the past few
years every effort has been made in many of these cities to
reduce the mortality from phthisis, whereas in Baltimore
practically nothing has been done, the comparison is still

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

289

more comforting. In order to have a more definite idea of
tlie disease as it exists to-day in the city, I have endeavored
to study the conditions in the different wards and districts
with the hopes of getting an idea of the relative prevalence
of the disease in the several sections of the city. This I
have found to be extremely difficult as there are at present
no means of ascertaining either the number or the location
of cases. It has been estimated that there are to-day about
10,000 consumptives in the city, and until some method of
notification of registration is adopted, it will be impossible
to study the distribution of the disease except through ac-
quaintance of small areas personally visited or from a study
of the annual death list.

Through the courtesy of Dr. C. Hampson Jones, our as-
sistant health commissioner, I have been privileged to show
you this evening a map prepared by him, showing the exact
location of every death from pulmonary tuberculosis from
January 1, 1900 to January 1, 1901, copied directly from
death certificates on file in the office of the health depart-
ment. On this map the white pins represent the deaths
among the whites, and the black pins give us an idea of the
ravages of the disease among the negroes. The city, as you
see, is divided into twenty-four wards, varying in population
from 16,.500 to 35,000, and containing from 2500 to 9000
dwellings. The ninth, eleventh, twelfth, sixteenth, seven-
teenth, eighteenth and nineteenth are largely suburban,
although comparatively thickly settled in some portions. In
these wards where fresh air and sunshine are plentiful, the
death rate from tuberculosis is low, averaging during the
past year only about six per cent. The only region to which
I wish to call your attention in these outskirts of the city is
Hampden, a small village settlement between Jones' Falls and
Woodberry, and populated largely by mill hands. In this
neighborhood there occurred last year seventeen deaths from
pulmonary tuberculosis, and I personally at present know of
four cases from this suburb undergoing treatment at the
Johns Hopkins Dispensary. Notice how few cases occur in
the neighborhood of Clifton, Druid Hill Park, Walbrook and
Irvington, all localities fully as thickly populated. It is
interesting to know how few deaths have occurred in the
extreme southern sections of the city and around Locust
Point. These are all regions thickly settled, occupied by
laboring people, in some houses very much crowded, and liv-
ing under the most imhygienic surroundings. Yet you see
that only three deaths resulted from phthisis during the
past year in this part of the city. This I believe, is due to
the existence of the large gas works which impregnate the
air with fumes from their furnaces, thus rendering it, to a
certain extent germicidal. I have been informed by prac-
titioners of this neighborhood that consumption is of ex-
tremely rare occurrence in this part of the city, and this
explanation seems interesting as well as satisfactory.

The part of the first ward bounding the basin and con-
taining the shipping and dirtiest business section of the city,
and the second ward, in which are located the great majority
of shops, warehouses and public buildings, have a compara-

tively low death rate from phthisis, owing to the small popu-
lation and few dwellings.

One could not have better proof that tuberculosis is essen-
tially a filth disease, flourishing in unhygienic surroundings,
than to know how practically exempt from the disease the
better residential sections of the city are. For example in
the 13th ward, in an area bounded by Franklin Street on
the south. North Avenue on the north. Park Avenue on the
east and Jones" Falls on the west, there have been no deaths
during the past year from tuberculosis. Again in the 15th
ward, in the neighborhood surrounding Eutaw Place, between
Druid Hill and Park Avenues, there have been no cases of
phthisis reported to the health authorities. But to the
west of Druid Hill Avenue, where our melanotic citizens
predominate, the death rate from consumption is little short
of appalling. In the lith ward, with an estimated popu-
lation of 23,000, there are 12,000 or more negroes. The
death rate from tuberculosis in this ward for the past year
was a trifle over 18;^. There is scarcely a block in this ward
in which there has not been reported a consumptive death
during the past year. Quite recently I have been making
a house to house visitation in some of the neighborhoods
especially infected, and the results promise to be most inter-
esting. In one house especially I have found that during
the past two years there have been three deaths from tuber-
culosis in one family, which had previous to the occupation
of this house been perfectly healthy. Upon questioning the
neighbors, I learned that the previous occupant had died of
lung trouble shortly before the present family moved in. A
small triangular section, bounded by Eichmond, Cathedral
and Biddle Streets, is an area of considerable interest, as
it is a part of the city familiar to most of us, and also because
it serves as an especial menace to those portions of the city
previously mentioned as being free from the disease. In this
small area there were ten deaths during the past year from
phthisis, seven blacks and three whites. I would like to
call your attention to the 10th ward, one of the smallest of
the city, bounded by Jones' Falls, Preston, Caroline and Mon-
ument Streets. This little ward has a greater population per
acre than any other ward, with a total death rate of about
500, and a percentage from phthisis, of about 15;^. The
adjacent ward, the Sth, in which this hospital is located, one
of the largest wards of the city, has the greatest number of
actual deaths per annum from tuberculosis, averaging between
90 and 100. But a correspondingly large total mortality
brings the ratio down 10^. This ward has about the same
population as the 10th, but scattered over an area of nearly
twice the size, and occupjang four times as many dwellings.
Does it not therefore seem probable from the above that over-
crowding, poor ventilation and lack of fresh air and sunshine
are not the sole causative factors in the spread of the disease,
but that certain districts seem to be more especially tainted
with tuberculous infection than others, and that to a certain
extent, where one lives seems to be as important as how one
lives. The degree of elevation has seemed to have little
effect upon the distribution of the disease. The difference

290

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

between sea level and the highest point in the city is only
that of a few hundred feet, and as I have already shown some
of the worst infected districts are in sections of the city com-
paratively high, whereas in the neighborhood of the water
front and Locnst Point the disease is of unusnally rare occnr-
rence.

What may be the best practical methods of reducing
the dangers from tubercnlosis are problems of such enormity
as to be entirely beyond the scope of a paper of this length,
suffice it to say that it is only a question of time before our
municipal authorities will be forced to adopt stringent regu-
lations, such as have proven successful elsewhere in checking
the spread of the disease. Maryland, unlike many of our
States, has as yet done nothing, but the legislatures of New
York and Pennsylvania have already passed laws requiring
registration of all cases of tuberculosis at the offices of the

health department, thus placing consumption upon the list
of notifiable diseases. Dr. Herman Biggs, of the Now York
healtJi department, at present estimates that he is enabled
to have under surveillance 9/10 of all plitliisical subjects.
By forcing some and by teaching others to properly dispose
of their expectorations, and by disinfecting the quarters of
the patient after death, he believes that he has in the past
six years reduced the mortality nearly 3.5';^, which means the
saving of 1.500 lives annually. If to this society can be
given the credit of stirring up in Baltimore such interest as
may be necessary to insure the adoption of similar prevent-
ive measures, surely the idea which originated its foundation
will have been a happy one.

N. B. — The numbers and boimdaries of the city wards re-
ferred to in this paper are those which were in existence at
the time of its first presentation.

CONCERNING A DEFINITE REGULATORY MECHANISM OF THE VASO-MOTOR CENTRE WHICH
CONTROLS BLOOD PRESSURE DURING CEREBRAL COMPRESSION.^

By Hakvet Gushing, M. D.

During the course of a long series of observations under-
taken for Professor Kocher in the Physiological Institute
of Bern in an attempt to elucidate certain questions of dis-
pute regarding the circulatory phenomena which are con-
sequent upon cerebral compression, it has been observed that
there is a constant tendency on the part of the blood pres-
sure to remain at a level above that of the pressure exerted
upon the brain.

The fact that cerebral compression occasions a rise in
blood pressure is universally known but it does not seem to
have been recognized that the degree of this elevation occurs
pari passu with the degree of compression (measured in mil-
limetres of mercm-y) to which the medullary centres are sub-
jected. It is ordinarily stated by the numerous experimen-
ters who have dealt with problems of compression that fatal
symptoms originate when the intracranial pressure approaches
or reaches the height of the arterial tension. The fact that
the arterial tension is a varying quantity which regulates
itself so as to overcome the effects of the increased intracra-
nial pressure seems never to have received attention.

In the greater number of my early observations the ex-
perimental compression has been made by means of quick-
silver which was allowed to enter a thin rubber bag at the
end of a metallic canula which was screwed into a trephine
opening in the skull. By this method it was impossible to
estimate with exactitude the degree of compression exerted
against the medulla since the elasticity of the bag, the re-
sistance of the dura in spite of its preliminary liberation from
the skull, and the fact that the brain does not transmit the
pressure from such a localized foreign body equally in all

' Eeprinted from the Archives Italiennes de Biologic for 1901.

directions were always elements of uncertainty in the calcu-
lation. Nevertheless the method sufficed to call attention
to the fact above mentioned, namely, that when the degree
of compression was increased so as to exceed that of the blood
pressure the latter would in turn almost invariably rise to a
level exceeding that of the intracranial tension. In this way
the blood pressure could be carried to indefinite heights,
occasionally to 250 mm. of mercury or more, and be held
there until the centres in the medulla became permanently
fatigued.

The suggestion tlius offered as to a definite regulatory
mechanism which counteracts the compression anaemia by
elevation of blood pressure was further strengthened by
direct observation, of the cerebral circulation through an
accurately fitting glass window inserted in another trephine
opening under which the dura had been opened. When the
intracranial tension had been carried up to the point of
blanching the convolutions and indeed of obliteration of the
pial arteries themselves, it could be seen through this fen-
estra that this condition of anaemia was but a transient one,
since in a few seconds the vessels would once more fill and
the circulation become reestablished. On some occasions,
to be explained later, the circulation could be seen to appear
and disappear with rhythmic periodicity, the intracranial
tension meanwhile remaining at the same level.

The opportunity of testing the truth of the hypothesis
thus suggested has been offered in the Lahoratorio di Fisio-
logia of Turin ' where a simple but more graphic method of

s I am deeply indebted to Professor Mosso in Turin and to Professor
Kroneekerin Bern for extending to me the privileges of their labora-
tories while carrying out these observations.

THE JOHNS HOPKINS HOSPITAL BULLETIN, SEPTEMBER, 1901.

-i^~.^w.:,^^

mmmmtAj

Chart II. After division of the vagi. Intracranial tension cai

Chart III.— Animal in normal condition. Intracranial tension brought rapidly to the point of exc
the Qsnal temporary vagus inhibitory effect.

jL^^ CK — -.

Chart V.— After section of both vagi and spinal cord. Increase of intracranial tension to li)2 mm. with

THE JOHNS HOPKJNS HOSPITAL BULLETIN, SEPTEMBER, 1901.

PLATE XXXIM.

'\\ X

1 H ^rm^ orl[liuL

Chart I, — Animal In normal condltioQ. lotracraolal tension Increaeed to 196 mm. of Sg, carrying with It the blood preaaare from Its normal level at 114 and prodnclng vaso-motor carvea.

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

291

demonstrating this coincidence of blood pressure and degree
of intracranial tension has been employed. In this Turin
series of observations the animals employed have been invari-
ably dogs. In Bern the same phenomena have been ob-
served in other animals.

Method of Experimentation. — A preliminary injection of
morphia has been given and the animals have been lightly
anffisthetized with ether.

Blood pressure has been recorded from the femoral artery
lest the ligation of one of the carotids should in any way
disturb the intracranial circulation.

For direct observation of the circulatory condition of the
brain a large trephine opening has been made in the median
line in such a situation as to avoid the large emissary veins
which pass between dura and diplote not only from the great
lateral cerebral veins anteriorly but posteriorly from the
torcular itself. The dura is opened to one side of the longi-
tudinal sinus exposing part of a convolution, its limiting
sulci and the pial vessels. In the trephine opening an ac-
curately fitting glass window is inserted through which the
degree of distension or compression of the longitudinal sinus
(unless the animal be very old), the condition of the cap-
illary circulation in the exposed convolution and the vas-
cularity of the pial vessels can be beautifully seen during
the subsequent experiment.

The intracranial pressure has been produced and recorded
as follows. Another, much smaller trephine opening is made
over one part or another of the cerebriim, cerebellum or cord
(in the latter case by trephining the lamina of one of the
vertebrae). The underlying dura is carefully and freely
opened. In the trephine hole an accurately fitting metal
canula is screwed to which a firm rubber tube is attached
communicating with a flask of physiological salt solution so
arranged that it may be raised or lowered for the production
of pressure to any desired level (cf. sketch). The rubber
tube leads through a basin of hot water so that the fluid
entering the cerebro-spinal space may be approximately at
body temperature. The tube furthermore communicates
with a mercury manometer which thus registers the degree
of intracranial terfsion. In this way the cranial cavity is
converted into a plethysmograph and the volume-pulse as
well as the tension of the liquor can be graphically
represented.

The blood pressure and intracranial tension may thus be
recorded side by side on a kymographion, the manometers
being so arranged that the zero pressures are taken from the
same abscissa, (of sketch).

Eespiration and time, the latter with a two second interval,
are also recorded on the charts.

By the devices ordinarily made use of for the production
of cerebral compression, especially by the introduction over
the hemispheres of circumscribed bodies, solid or otherwise,
no exact indication of the degree of pressure over the medulla
is given siuce it is well known that pressure so applied is
not transmitted equally throughout the three large cerebral

chambers which are limited by tentorium and falx. In some
animals indeed the brain may be so dislocated that the
medulla may to a large extent be crowded through the fora-
men magnum and the vaso-motor centre thus partially es-
cape from the compression effects to which the cerebrum is
subjected. For this reason it was essential for our purposes
to employ a method in which the intracranial tension over
the fourth ventricle was to all intents and purposes equal
to that which we were measuring in millimetres of mercury
at the pomt of application of pressure. In no other way
could au accurate comparison with the blood pressure be
made.

It miglit be 'supposed and has heretofore been stated that
the extraordinarily free communication between the cerebro-
spinal space and the cranial venous circulation would lead
to a rapid overfilling of the right heart, should a continuous
supply of artificial liquor under an abnormal pressure be
afforded. As a matter of fact during life and when the
blood pressure remains above that of the intracranial tension
this escape of liquor is not exceedingly rapid. During a
long experiment with the intracranial tension of this fluid
varying from one to two hundred millimeteres of mercury
and so held from ten to twenty minutes at a time, on an
average only 80 to 100 cc. of the salt solution would be
taken up by the circulation, certainly not enough to alter
the reliability of the observations. On the other hand, after
the death of the animal with a zero blood pressure the liquor
enters the veins and thus the heart with much greater rapid-

ity.

Care must be taken that the dura corresponding to the
trephine opening for the canula be accurately excised and
that the compression fluid be not allowed to enter from
a high pressure with too great abruptness since under such
conditions the dura may be flattened against the brain and
the fluid collect as a foreign body between the membranes
and skull instead of passing freely in all directions
over the entire central nervous system. Under these
latter circumstances and provided that the pressure from
without is kept at a constant level the tension of the fluid
in the cerebro-spinal space is the same throughout and the
absorption which is in too small amounts to embarrass the
cardiac action, may be disregarded. Thus, very slight, if
any, differences can be observed in the regulatory mechan-
ism to be described, whether the fluid be allowed to enter
primarily, over cerebrum, cerebellum or cord.

The accompanying charts demonstrate more plainly than
can any description the striking regulatory phenomena on
the part of the blood pressure, as controlled by the vaso-
motor centre, which occurs during varying degrees of medul-
lary compression.

Until the intracranial tension (" Hirndruck ") exceeds that
of the blood pressure, nothing more than the usual slight
excitatory phenomena (cf. Chart I) are seen, indeed if the
fluid enters easily without' compromising the sensitive dura
this primary quickening of pulse and respiration may be
absent (cf. Chart III.)

292

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 12fi.

Wlien, however, the pressure is increased until it exceeds
that of the blood pressure and especially if this high intra-
cranial tension has been rapidly produced (as in Chart III)
we may occasion momentarily the so-called major symptoms
of compression with Kussmaul-Tenner spasms, evacuation of
bladder and rectum, practical cessation of respiration and
pronounced vagus effect upon the heart often with a complete
" Stillstand " lasting from ten to twenty seconds. Then fol-
lows a release from this extreme vagus inhibition and the
vasomotor centre begins to exert its striking influence.

In the more simple condition when the pressure has been
increased more slowly (Chart I), these vagus symptoms .ire
often avoided and the rise in blood pressure follows imme-
diately upon the increase of " Eirndruck " to a level which
temporarily exceeds it. Under these circumstances and when
tlicre has been no pronounced vagus effect (as in C'hart III,
where the sudden release from vagus inhibition has tempor-
arily let the vaso-motor action run away with the blood
pressure) it can be seen that the rise in blood pressure is
merely sufficient to carry it above the level of the compres-
sion fluid, in other words an arterial pressure is called out
which suffices once more to carry blood to the centres in the
medulla. If, as in Chart III, an unnecessary elevation of
blood pressure has primarily been occasioned it will fall and
continue along a line representing a level slightly above that
of the compression. Should the intracranial tension be
again increased the same phenomena will be again repeated
(cf. Chart I), and in this way the blood pressure may be
forced to a level considerably over 200 mm. of mercury be-
fore the vaso-motor centre shows signs of giving way r.nd
fails to respond to the demands of an ansemic medulla.
Within reasonable limits of compression, however, this
compensatory action may be indefinitely prolonged.

On many occasions, as in Chart I, the blood pressure may
be seen to rise and fall, above and below the line represent-
ing the degree compression, with a rliythmic periodicity of
one form or another (Traube-Hering waves, etc.). This
phenomenon is readily explained by observation through the
glass window of the circulatory condition of the brain,. a state
of absolute aneemia accompanying those periods when the
blood pressure is below the level of the compression line, an
abundant circiTlation being present when it is above. As the
average line of blood pressure is raised to a higher level by
increasing again the degree of intracranial tension it carries
with it this same rhythmic activity (cf. Chart I).

It is the object of this communication merely to state the
existence of the regulatory function above described, and the

writer makes no pretense at theorizing over the physiological
laws which govern it. However, the following observations
demonstrate that the process depends largely for its action
upon the vaso-motor centre and the control which the latter
exerts over the great splanchnic circulation.

1. If the vagi be divided and comjiression subsequently be
made upon the brain, the blood pressure will be seen to cor-
respond even more closely than before to the degree of intra-
cranial tension (cf. Chart II) always remaining slightly
higher than tlie pressure exerted against the medulla or else
passing above and below it with wave-like rhythm. The
vagus effect (as shown in Chart III) of course is absent under
these circumstances.

2. If a coil of small intestine be exposed, during such a
compression experiment as has been described, the splanch-
nic vessels can be seen to contract during the rise in blood
pressure and to dilate once more as the latter falls at the
end of the experiment.

3. Again if through a trephine opening in the atlas the
spinal cord be divided with a blunt instrument so as to occa-
sion the slightest possible bleeding, and then pressure be ap-
plied, the vagus effect alone will be forthcoming with no rise
in blood pressure (cf . Chart IV), at least until the independ-
ent spinal centres shall have asserted their individual
activity, when a slight rise may he occasioned.

4. If both vagi and cord be thus divided an increase in
intracranial tension does not affect in the slightest degree the
level of blood pressure (cf. Chart V.)

5. Similarly cocainization of the medulla by the introduc-
tion of the needle through the occipito-atlantal ligament,
throws out the action of the bulbar centres. TTnder these
circumstances, if artificial respiration be instituted the
animal may live with a temporarily paralysed vaso-motor
centre and an increase of intracranial tension does not affect
the blood pressure until the cocaine effect begins to wear
away.

As a result of these experiments a simple and definite law
may be established, namely, that an increase of intracranial
tension occasions a rise of Mood pressure which tends to find
a level slightly above that of the pressure exerted against the
medulla. It is thus seen that there exists a regulatory mech-
anism on the part of the vaso-motor centre which, with
great accuracy, enables the blood pressure to remain at a
point just sufficient to prevent the persistence of an anaemic
condition of the bulb, demonstrating that the rise is a con-
servative act and not one such as is consequent upon a mere
reflex sensory irritation.

THE JOHNS HOPKII^S HOSPITAL BULLETIN.

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

293

PENDULOUS TUBERCLES IN THE PERITONEUM.

By W. G. MacCallum, M. D.

As has long been kuown, there are formed in the Perlsucht
or peritoneal and pleural tuberculosis of cattle masses of
various sizes, of caseous or calcified material surrounded by
a fibrous capsule and embedded in a loose proliferated con-
nective tissue arising from the subperitoneal tissue. These
masses often reach very considerable dimensions, and from
their weight become pendulous, drawing out the underlying
tissue into a stalk — often there are adliesions and such band-
like adhesions bearing several caseous nodules have somewhat
the appearance of a string of pearls, whence the name.
Virchow's ' illustration and description of this condition are
very accurate, although he considered it a form of lym-
phosarcoma.

In human beings, however, such a form of tuberculous
peritonitis is not so common, and I have been able to find
in the literature the description of only oue such case; Biz-
zozero,' who describes this case was unable to find records
of a similar case, and in the admirable reviews of the recent
literature by v. Bruuu,' there is no mention of such a con-
dition.

Bizzozero's case was that of a young peasant 34 years old,
who died with the diagnosis of pulmonary tuberculosis. At
the autopsy the lungs were found to contain masses of con-
glomerated tubercles, and there were already cavities at the
apices. In the peritoneal cavity was a litre of seropurulent
fluid and the intestinal loops were firmly adherent to one
another and to the liver by means of a yellowish exudate,
which was also found between the liver and the diaphragm.
On removal of this exudate covering the intestines, it was
found that the peritoneum, both visceral and mesenteric,
was covered with most numerous whitish tuberculous nodules
of the size of the finest grain of millet to that of a pea.
Sometimes they united to form a plate of the size of a five
lira piece. Numerous tubercles were found in the parietal
peritoneum and subserous connective tissue also. The mes-
enteric glands were enlarged — microscopical examination
shows in them the usual tuberculous detritus.

The mucosa of the stomach was normal, but in the ileum
it was pigmented, and numerous tuberculous ulcers corre-
sponding with which there were especially numerous tuber-
cles on the peritoneum.

More careful examination of the peritoneal tubercles —
especially those of the mesentery, demonstrated that their

' Virchow, Krankh. Gescliwiilste, ii.
' Bizzozero, Morgagni, vol. ix, 1867.
»voD Brunn, Centralbl f. Allg. Path,
and 2, 1901.

Path. Anat., Bd. xii, No. 1

nature was varied enough. Some were embedded in the
tumefied peritoneum and showed only as spots of rather
white color — others produced a sensible elevation — others
projected by their whole height above the level of the peri-
toneum— finally others were not attached at their point of
origin except by a peduncle of a length varying from a mil-
limetre to a centimetre, and varying in diameter from 1 to
^ or ^ of a millimetre — often the peduncle was flattened
together, so that with a width of ^ centimetre it might have
a thickness of only ^ to 1/10 millimetre. The histological
constitution of the tubercles immersed in the peritoneum
and those with peduncles was the same, and as usual had
outside a layer of connective tissue in active proliferation
and internally the elements in detritus and fatty degenera-
tion.

" The microscopical examination of the peritoneum," he
says, " shows me the probable reason why, while in other
cases of tuberculosis the small neoplasms are adherent to the
peritoneum, in mine they were for the most part peduncu-
lated. The preparations show that the connective tissues
of the membranes were separated by an abundant hyaline
fundamental substance in which were numerous new-formed
cells, of which some were spherical or oval, others fusifoxm or
stellate — naturally the peritoneum, tumefied and softened by
the presence of superfluous fundamental substance and of
numerous new-formed cells could not support the weight of
the tubercles, and yielding, formed of necessity a peduncle.

" The layers of muscular fibres have taken no part in the
new formation. Only in the interfascicular connective tis-
sue was there proliferation of cells.

" This case leads me to believe that, in all probability, tu-
bercles might also produce a kind of free body in the perito-
neum, as is the case with fibromata, lipomata, etc., and even
sclerosed appendices epiploicae (Virchow, Krankh. Geschw.,
i, p. 38-1).

The case which occurred in this hospital was that of a
- white woman, aged 38, who died with symptoms of pulmo-
nary tuberculosis.

At the autopsy, the peritoneal cavity was found to contain
no excess of fluid, and the peritoneal surfaces were smooth
and glistening. There were, however, nodules lying just
under the serous surface, scattered over both parietal and
visceral layers. These had a most extraordinary arrange-
ment— they varied in size from 1 or 3 mm. to 2 cm. in
diameter. Some were sessile and flattened and projected
only a few mm. from the general peritoneal level, but most
of the nodules hung free, each in a sort of long blind tube

294

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

formed apparently by the drawing out of the peritoneum
into a tubular pedicle. Some of these pedicles reached a
length of 10 to 12 cm., although most of them were much
shorter and broader. The long ones generally took their
origin from a wide uplifting of the peritoneum, and in some
part of their length they were often narrowed to a width of
only 1 to 2 mm., when they became much twisted and
tangled with one another. All of these pedicles contained
fluid which if the terminal caseous nodule were allowed to
hang down, ran downward to the end of the tube, distending
it to a globular ball; by elevating the end, the somewhat red-
dish fluid could be made to run back and spread out under
the peritoneum over the intestine and perhaps even to enter
another tubular pedicle. In one or two cases such tubular
prolongations show no caseous mass at the end, and indeed
one elongated sac with extremely thin, delicate walls and clear,
yellow fluid contents was found entirely free in the peritoneal
cavity. This body tapered to a point at each end and, as de-
scribed above, the fluid could be allowed to run to either
end, forming a globular bubble-like distended mass, the re-
mainder collapsing • into . a delicate string. In some cases
large sessile caseous masses were found to be overlaid by a
loose peritoneal fllm which formed part of the wail of the
large pedicle of some other mass, and in others this up-
lifting of the peritoneum from the surface of the sessile
nodules was incomplete, so that the peritoneal fllm appears
to start from the middle line of the nodule — Anally in some
cases, small caseous nodules were found hanging by a stalk
inside the elevated peritoneum.

The peritoneum thus drawn up was furnished with numer-
ous widely dilated vessels — in some of the pedicles, however,
undue twisting had produced strangulation, and the tissue
had a dark purple color. Such pedicled nodules which were
opaque and yellow, and on section showed largo areab of
caseation, arose from and were attached to any part of the
peritoneum, parietal as well as visceral, and even from that
covering the pelvic organs. The intestinal mucosa appeared
normal except for two small ulcers in the coecum opposite
the attachment of one of the large subserous masses. The
lymph glands in the abdomen were apparently not involved —
lymph glands lying side by side with the caseous nodules
showed, even when examined microscopically, no alteration.
The cervical and mediastinal lymph glands, however, were
almost entirely caseous.

The spleen and liver were bound to the adjacent tissues
by old adhesions which contained caseous masses — tubercle-
like nodules could be seen in their substance on section.

The lungs were bound to the costal pleura by old adhesions
— they were somewhat emphysematous and studded through-
out with minute miliary tubercles — the bronchial glands were
not involved.

Finally there was a tuberculous leptomeningitis, the pia
mater over the pons cerebellum and cerebrum showing here

and there a yellowish exudate with tubercles along the ves-
sels.

Microscopically the nodules described in the liver, spleen
lungs, etc., proved to have all the histological features of
tubercles.

Sections wer-e made through the peritoneal nodules so as
to pass through the pedicle and the underlying tissue. The
nodules were necrotic with the exception of the peripheral
portion which had the characters of a tuberculous tissue
consisting of irregularly arranged epithelioid cells and giant
cells with very numerous lymphoid cells — externally a con-
siderable mass of elongated connective tissue cells formed the
capsular layer over which lay the peritoneal endothelium —
this last, however, not being always seen in the sections. The
architecture of the more central portions was sometimes
preserved enough to indicate that they had arisen from the
confluence of several smaller tubercles. Tubercle bacilli were
to be found in great numbers in these masses and especially
in the zone between the living and necrotic tissue in wliicli
the cells were degenerating and their nuclei becoming frag-
mented. The sessile nodules are embedded in an extremely
vascular tissue which indeed spreads out wide of them and
really forms also the pedicles of the pendulous nodules.
Microscopically this tissue consists of a very loose connective
tissue, in the interstices of which lie numerous round and
plasma cells, but especially characterized by the presence of
enormous numbers of very wide, thin-walled blood-vessels
distended with blood. This vascular tissue passes up over
the nodules, being fairly sharply marked off from the tuber-
culous tissue of their substance, and its presence explains the
appearance of the wide area of congestion about each nodule,
and the vessels described above as ascending to pass over
the surface of the nodule. Sections through a pedicle show
the same richly vascularized loose tissue in the wide clefts
of which runs the fluid described macroscopically as appear-
ing to be contained in a tube. Such tissue has, as Dr. Welch
suggests, great resemblance to the tissue found newly formed
on the dura mater in chronic internal hajmorrhagic pachy-
meningitis and he further tells me that he has observed
it in the peritoneum and especially in the pelvic peritoneum
of women without any associated tuberculosis. Indeed, as
stated above, there are in this case many vascular areas, and
even elongated pedicles without tubercles, and many long
pedicles support tubercles of only insigniflcant size which can
scarcely be thought of as having, by their mere weight, drawn
out the peritoneal tissue into its present form. So although
at flrst the mechanical effect of the weight of the tubercles
seemed to offer a probable explanation of these curious for-
mations, it now seems much more plausible to accept the
suggestion of Dr. Welch and to consider the tubercle masses
as formed, in part at least, in precxistent loose adhesions
and strands of vasctilar new-formed connective tissue, not de-
nying the importance of gravity in altering the appearance of
these strands when the mass had reached any considerable
size, or in some cases of initiating their elongation.

THE JOHNS HOPKINS HOSPITAL BULLETIN, SEPTEMBER, 1901.

PLATE XXXV.

The drawing shows a portion of the intestine, natural size, witli its mesentery, from wliich
arise the sessile and pcduueulated nodules described.

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

295

SUMMARIES OR TITLES OF PAPEUS BY MEMBERS OF THE HOSPPrAL AND MEDICAL SCHOOL
STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.

Frederick II. Verhoeff, M. D. A Case of Noma of the
Auricles, Due to the Streptococcus Pyogenes, and its
bearing on the Etiology of Noma in General. — The Jour-
nal of the Boston Society of Medical Sciences, Vol. V,
pp. 465-478, May, 1901.

The Theory of the Vicarious Fovea Erroneous. — The

Ophthalmic Becord, June, 1901.

Thomas B. Ftttcher, M. B. Syphilitic Fever, with a Ee-

port of Three Cases. — New York Medical Journal, June

22. 1901, p. 1065.

The importance of keeping in mind the fact that fever of

obscure origin is occasionally due to syphilis is emphasized.

With the onset of the secondary eruption there is nearly

always an elevation of temperature. This " fever of invasion "

is usually of a remittent type. Syphilitic fever, however, may

also be either continuous or intermittent in type. It may
occur as early as four weeks previous to the appearance of the
secondary eruption or as a late tertiary manifestation.

Syphilitic fever is frequently mistaken for malaria, typhoid
fever, tuberculosis, sepsis and occasionally rheumatic fever.
Attention is drawn to the importance of making a careful
examination of the long bones and viscera for evidences of ter-
tiary lues in all cases of fever, of obscure origin, also of admin-
istering potassium iodide and mercury as a therapeutic test.

The first case reported had an intermittent fever commen-
cing four weeks before the onset of the secondary eruption.
It resembled closely the fever of aestivo-autujnnal malaria.
The second case had a fever simulating typhoid and its true
character was determined by the finding of periosteal thick-
enings and by the cessation of the fever after administering
Iiotassium iodide. The third case had an intermittent fever
resembling malaria twenty-nine years after the contraction of
lues. ,

PROCEEDINGS OF SOCIETIES.

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Monday, April 15, 1901.

The meeting was called to order by the president, Dr.
Welch, who introduced Dr. Harvey E. Gaylord of the New
York State Pathological Institute at Buffalo, who spoke on
The Parasite of Cancer, with Demonstrations.

Discussion.

Dr. Welch. — Dr. Gaylord has brought before us something
more than the mere description of the so-called cell-enclo-
sures observed in hardened specimens of cancer. Of the en-
closures hitherto described in preserved material the only
ones which present anything like a definite organization and
which, it seems to me, have not been altogether satisfactorily
explained are the bodies first accurately described by Thoma
and Sjobring, and subsequently noted by most of those who
have studied this subject. These bodies in English and
American writings are often designated without much pro-
priety as "Plimmer's bodies." No conclusive evidence that
these bodies, still less that any other of the various enclosures,
are parasites, has been furnished, and it now seems evident
that no further progi-ess in the search for parasites is likely
to be made by the examination of hardened material with our
present methods.

Under these circumstances it is important to turn to the
examination of fresh material and to make attempts to culti-
vate parasitic organisms, provided such exist in cancer and
other malignant tumors. This direction of study has there-
fore been followed in recent years by several investigators,
and it is especially his results along these lines which Dr.

Gaylord has reported to us this evening. As regards artificial
cultures, it is certain that no forms of bacteria demonstrable
by existing methods arc directly concerned in the causation
of cancer, and, notwithstanding the stronger claims made in
behalf of Blastomycetes, I am glad to learn that Dr. Gaylord
rejects these claims and takes a position in this regard op-
posed to that of San Felice, Eoncali, Plimmer, Leopold, and
others. He interprets as Protozoa the bodies which he re-
gards as parasites.

Leaving out of consideration the occasional and accidental
presence of cultivable bacteria and yeasts in cancer, I ques-
tion whether what is called by Dr. Gaylord and other investi-
gators as the cultivation of protozoa or of sporozoa from
cancers should be so designated, and it does not appear that
secondary cultures carried on from generation to generation
have in any instance been secured.

There is not much agreement among the different ob-
servers either in the description or the interpretation of the
various bodies regarded by them as parasites to be seen in
fresh cancerous material or fluids, or in such material kept
free from bacterial contamination, whether mixed with some
cultural fluid or not. Dr. Gaylord lays especial emphasis
upon the presence in cancers and other conditions of homo-
geneous, yellowish, spherical bodies resembling droplets of fat
but without the usual reactions for fat, and he considers that
he finds evidences of multiplication of these bodies and of
their passing through a definite cycle of development which
he describes. He is, I trust, prepared for a considerable de-
gree of skepticism following this announcement of his results,
and it is desirable that this should be the attitude of mind
until we arc in possession of more evidence than has yet been

296

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

furnished in favor of the parasitic hypothesis. It is, how-
ever, incumbent upon pathologists to make a careful study of
all that can be seen in the microscopic examination of fresh,
macerated, and preserved cancerous material, and whatever
else may be the outcome of such studies, they will have fur-
thered our knowledge of cellular degenerations and meta-
morphoses. Unless there are those present who on the basis
of such study are prepared to discuss Dr. Gaylord's findings,
it does not seem to me worth while to discuss them in detail.
Dr. Gaylord has presented an instance of multiple nodules
in the lungs of an adeno-carcinomatous nature following the
intravenous injection of cancerous ascitic fluid. With this
exception and one or two more doubtful cases his experi-
mental results, so far as the reproduction of malignant tu-
mors is concerned, are, like those of other investigators in the
same line, negative.

May 6, 1901.

The meeting was called to order by the President, Dr.

Welch.

A Case of Pseiulo-parasitlsm. Dr. Stiles.

Exhibition of Medical Cases. A Case of Charcot's Joints involv-
ing both Knees. Uk. Futchek.

This colored man is 68 years of age and manifested the
first symptoms of tabes seven years ago in the form of light-
ning pains in both lower extremities. Two years later the
right knee suddenly became swollen and inside of two weeks
he noticed that the knee would give laterally whenever he at-
tempted to bear his weight on it. Two weeks after the
onset of the symptoms in the right knee the left knee became
similarly involved. There was no pain at the onset, and
there has been none throughout its course. In November,
1900, the right knee suppurated and was opened. The knee-
joints, as you observe, now show the most marked deformity.
The tibia on both sides is dislocated outwards on the femur,
and there is very extensive lateral motion with hyper-exten-
sion of both knee-joints. The condition presented is that of
Charcot's joint complicating tabes dorsalis.

Charcot first described the joint affections associated with
tabes in 1868. The joints involved are usually the large ones
and rarely, with the exception of those of the feet, are the
small joints of the body affected. The joints of the lower
extremities are more frequently affected than those of the
upper. Chipault collected 368 eases of tabetic arthropathies,
of which 120 were in the knee and 57 in hip joints. The
character of the changes in the joints varies greatly with
the type of the joints, as to whether they are ball-and-socket
or hinge joints. In the first, such as the shoulder and hip,
atrophy is more likely to occur than hypertrophy. In the
knee, hypertrophic are more common than atrophic changes,
and consequently there is more deformity. This complica-
tion of tabes often occurs comparatively early in the disease,
and some observers say it may be the fiirst symptom to attract

the patient's attention. On the other hand some cases may
come on very late in the affection.

The tropho-neuroses in tabes dorsalis are varied and di-
vided by some into the osteopathies, arthropathies and osteo-
arthropathies. To the osteopathies belong the spontaneous
fractures in the long bones. The arthropathies include the
cases with Charcot's joints. The osteo-arthropathies com-
prise those cases where the joints and bones are involved
together, and in this group belong the vertebral lesions with
kyphosis, as well as those cases of tabetic feet where the foot
is foreshortened because of dislocation of the metatarsus
backwards on the tarsus.

In the hypertrophic form of Charcot's joints the exami-
nation will show destruction of the cartilages with hypertro-
phy of the synovial fringes and thickening of the ends of the
bone with rarefaction and consequent softening of the bone
tissue. Occasionally the cartilages may be eburnated, but
this is uncommon.

As to the treatment of tabetic joints there is very little that
can be done to give permanent relief or improvement. In
recent years an effort has been made to secure relief by excis-
ing the joints. We have had one case here in which excision
was performed two years ago. The upper end of the tibia
and the lower end of the femur were excised and the two
extremities coapted, but at the last rejjort imion had not
occurred. An interesting point was that the patient did not
require an aufesthctic. He lay on the table perfectly con-
scious of what was going on. The bones were sawn through
and the periarticular tissue removed without his experien-
cing the slightest pain. In the case before you the patient
did not suffer any pain when the right knee-joint was opened.

Protozoic and Blastomycetic Dermatitis, with Lantern slide
Demonstrations and Exhibition of a Case. Dr. Gilchrist.

Discussion.

Dr. Stiles stated that when the cases first came up speci-
mens of the parasites were submitted to prominent botanists,
who concluded that they did not belong to the plant kingdom.
After this opinion had been expressed by several well-known
mycologists, he had reluctantly adopted it, and because of
the resemblance of the parasite to Coccidium, and because
of its method of reproduction, he had placed it in the spo-
rozoa. He had advised Doctor Gilchrist to classify it tem-
])orarily in the microsporidia, chieily because he did not see
in what other group it could be placed, and not because he
felt positive that it was a true microsporidium. The case at
hand was an excellent example of the diiSculty which fre-
quently arises in determining whether a given organism is
an animal or a plant.

May 20, 1901.

The meeting was called to order by the President, Dr.
Welch.

Exhibition of Medical Cases. Dr. Osler.

Case 1. — This patient was admitted May 16, complain-

Septej[bee, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

297

ing of stomach trouble. He is a laborer, aged 37— had
jaimdiee wheu seven years old, which lasted about a year,
and wliicli is a point of interest in his history. Since then
he noticed a yellow east of the eyes whenever he felt badly,
though we could not get a distinct history from him of
permanent slight jaundice. There is no history of any acute
illness of any moment. He has been a heavy eater and a
drinker of beer from his sixteenth year, but has not used
whisky. There is a suggestive history of lues.

Tlie onset of his illness occurred May 7 with cramp-like
pains on the right side, just luider the ribs. He worked
all that day and obtained relief from his pain by forced
vomiting. A slight pain continued for several days but did
not j)rovent his working. He lost ten or twelve poimds in
weight before admission. He has had no fever :ind is a
robust, rather healthy looking individual. In this light you
do not especially notice the jaundice, but it is one of those
instances where, having seen him in daylight and having his
color fixed upon your mind, you can see that he is a little
jaundiced. The point of special interest is the abdomen.
Yf)U can readily see a slight fullness in the left umbilical
region, and as he draws a deep breath you notice a distinct
shadow. There is a marked difEerence between the infra-
costal grooves on the two sides. On palpation, there is in the
left hy]iochondriac region and extending into the umbilical
and epigastric regions a solid, firm tumor mass, the edge of
which can be readily felt below and to the right. This mass
is rounded, firm, very mobile and the hand can be passed
behind it pushing it forward. Its edge is felt to be distinctly
notched. There is no question at all that it is an enlarged
spleen. It is a spleen of moderate size and not one of those
that reaches almost to Poupart's ligament.

On examination the liver edge can not be felt on palpation
at first, but on deep inspiration the edge descends and can be
felt at the time of extreme inspiration. On percussion you
notice a small area of hepatic flatness, not more than two
fingers' breadth, and there is no ascites. He feels well and
the jaundice and pain, which latter is better now, are the
only two featvires of which he complains. His blood does
not show any marked anemia; there is no leucocytosis and
the haemoglobin is 70^/.

The interesting features are the presence of a very large
spleen, with a very small liver, and jaundice without anemia.
The case belongs to those interesting groups of which we
have had a number of cases lately, illustrating the association
of enlarged spleen with cirrhosis of the liver. There are
several different conditions in which we may have spleno-
megaly with cirrhosis of the liver.

First, it is the rule in cirrhosis of the liver to have a big
spleen and in a few rare instances in ordinary cirrhosis from
alcohol the spleen reaches an enormous size. Some of you
may recall a case we had in the hospital two years ago which
we thought at first was very probably one of primary disease
of the spleen, but which was shown later to be an enlarged
spleen associated with a diseased liver.

Second, in all eases of hypertro])hic cirrhosis, particu-

larly those of the so-called Hanot type, the form that occurs
in young children and persons without an alcoholic hii^tory,
there is no ascites, but a permanent slight jaundice. Some-
times there is a very large spleen in these cases, a spleen
equaling in size, or even exceeding the size of the liver.
Many of you recall the two brothers (White) who were here
for several years under observation, both having very large
spleens. There is a good series of pictures in the last number
of Guy's Hospital report with an article by Dr. Taylor par-
ticularly illustrating this form.

Third, there is an interesting group of cases, which wo
have been studying carefully during the last few years, in
which there is a primary enlargement of the spleen associated
with slight, but characteristic anasmia. Some of these cases
show no anemia, but progressive enlargement of tlie spleen,
sometimes without any other symptoms whatever. Such a
patient may come, as some of our cases have, not complaining
of the spleen, or of abdominal pain, but with hemorrhage
from the stomach. In a certain number of those eases the
liver has been atrophic. Banti, of Italy, has studied a num-
ber of them and the condition has been called Banti's disease.
The ana?mia is of the chlorotic type and as a late sequence
there is cirrhosis of the liver. We have had two such cases,
one of which was operated upon by Dr. Gushing for removal
of the spleen which had been enlarged for eight or ten years.
In that case there was a well marked ordinary cirrhosis with
anemia. The second case was operated upon by Dr. Halsted
a few weeks ago and here the liver was cirrhotic and the
condition had lasted for six or eight years.

The case before us I think may be called a primitive
splenomegaly with cirrhosis of the liver. He has been a beer
drinker it is true, but you rarely get a marked cirrhosis in
such people at this time of life and he has not the facies of
ordinary cirrhosis.

Case 2. — I wish to show this case for just one point. It
is a case of scurvy with an unusual condition of the skin of
the legs. In a few instances of scurvy there are very exten-
sive subcutaneous hemorrhages particularly about the thigh
and knees, and they may be so extensive and diffuse that the
leg is in a sclerotic or scleremic condition. We have had one
ease in which the patient could not straighten his legs when
he attempted to walk btxt simply shuffled them along. This
man came in with swollen gums, with hemorrhages, and an
enlarged knee. Aspiration showed bloody fluid in the knee-
joint. The swelling is such that you can not pick up the
skin at all on the hemorrhagic side. The condition is known
as scorbutic scleroderma. The patient has only been in this
country about a year, working at Locust Point, and has
eaten practically nothing but meat and bread during that
time.

Dr. AVelcii. — What is the value of treatment by extirpa-
tion of the spleen in Banti's disease?

De. Osler. — In Dr. Gushing's case, where the condition
had lasted for eight or ten years, the spleen was removed,
with complete recovery, and the patient has been well now
nearly two years. In the second case that was operated upon,

298

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

the patient did very well for more than a week and then
had a recurrence 'of the hemorrhages and died with a very
profuse hemorrhage, which the post-mortem showed was
from an cesoi^hageal varix. The third case operated upon a
few weeks ago by Dr. Halsted had a very large spleen with
hemorrhages recurring for sis years, and on four or five
occasions the patient nearly bled to death. At the opera-
tion the splenic veins and arteries had been tied but in
attempting to remove the adhesions between the spleen ?nd
the diaphragm an uncontrollable hemorrhage occurred and
Die patient died.

Drainage of the Bladder and Cystoscopic Examinations. Dr.

Kelly.

Dr. Kelly spoke of drainage in bad cases of cystitis. Here
attempts to wash out will be cut short on account of tlie
pain. Dr. Kelly treats such cases by placing the patient in
the knee-breast position and letting air into the bladder
through the cystoscope. He then thrusts in a narrow-bladed,
specially made knife, set at an angle with the handle, and
draws it downward towards the urethra, leaving a free open-
ing into the bladder for escape of urine. Dr. Kelly urged
the importance of making topical examination of the bladder
before commencing treatment in cases of apparent cystitis.
He had had eases which had been treated elsewhere for a
length of time for cystitis, when on using the cystoscope a
stone was seen, and in its removal the s3'mptoms disappeared.
He spoke also of peculiar cases of pregnancy which he does
not understand. One part of the uterus softens down and
the rest remains rigid; the softened part may bulge. In his
case it was mostly towards the patient's right. The patient
was the wife of a physician from Iowa. He was advised to
let it alone and returned home, where his wife had a normal
labor. In another case, the wife of an army surgeon, the
abdomen was opened and the right upper horn of the uterus
found to be softened. The patient later aborted per vias
naturales. In a third case exactly the same condition was
found. Dr. Kelly would call it " apical pregnancy," and it
is liable to be mistaken for extrauterine preg-nancy.

Observations npou Smallpox. Dk. Utlky J. Porter, oi Co-
lumbia, Teuu.

Dr. Porter described an epidemic that has recently pre-
vailed in that section of Tennessee in which he lives. For
a time the diagnosis was in dispute, some regarding it as
chicken-pox, others as a new sort of eruption, " the bumps,"
and a few diagnosticating true smallpox. Meanwhile, in the
imcertainty there was no efficient action or isolation, and
the disease spread until there were 1000 cases. Dr. Porter
exhibited casts of the eruption and threw pictures on the
screen, showing that the disease differed in no way from the
smallpox of the text-books, there being cases of hemorrhagic,
confluent, semi-confluent and discrete smallpox, as in other
epidemics. The mortality also was the same, all the hemor-
rhagic cases (5 or 6) dying; 40 per cent of the confluent, and
10 to 15 per cent of the discrete. Old persons over 75,

pregnant women and infants under 18 months are usually
exempted from the need of vaccination, but none need it
more than these persons. In the 1000 cases there were some
15 of the disease in the fetus in utero, several of which Dr.
Porter had himself delivered.

Discussion.

Dr. Fulton-. — It is very fortunate for the State of Mary-
land that a dispute about the diagnosis of this disease has
not arisen here. I doubt whether anybody would have made
and defended the true diagnosis in the way it has been done
in Tennessee. Some of the big wigs in that State were on
the side of chicken-pox in that controversy. Before engag-
ing in a controversy with a man who collects evidence so
carefully and presents it so vividly, one must be very sure
that he is right, for there are only two alternatives, to be
right or to run. In Tennessee the big wigs ran, as wise
men should in such a predicament.

It is not surprising that errors of diagnosis have been fre-
quent in the history of the smallpox epidemic now prevail-
ing in the United States. The disease itself departs widely
from the text-book descriptions, though not more widely than
typhoid fever does; and these variations are no less manifest
in its epidemic characteristics than in the individual cases.
The medical student of to-day has no chance to observe the
disease, and has therefore no mental picture of the disease
other than that gained from the text-books. Comparatively
few physicians under 50 have seen the disease, while the older
men remember the disease by the more impressive character-
istics of its appearance years ago.

Besides, there are fundamental reasons why the diagnosis
of the eruptive fevers should sometimes be difficult. Know-
ing as we all do in what varj'ing degrees the animal body
reacts to the infections, it seems strange that medical men
expect reactions to the same organism to be always similar
in kind. Every eruptive fever is known by its peculiar
dermatitis. Fortunately the appearances of the skin in
measles, scarlet-fever, chicken-pox, and smallpox arc usually
characteristic enough, in conjimction with other data, to lead
to correct diagnosis. Chicken-pox and smallpox are, how-
ever, strikingly alike at times, and in the present epidemic
this is particularly true. As one's experience grows, one
approaches the problem of diagnosis in each new isolated
case with increasing diffidence. Watching the whole evolu-
tion of the lesion, one should not go astray, but this delibera-
tion about diagnosis does not satisfy the demands of public
safety, nor the clamor of private interests, when smallpox
is suspected. It will be remembered that Hebra taught that
variola and varicella were one disease, and some of his pupils
still hold that doctrine.

The signs of the times, are but slightly hopeful that we
shall soon have identified the contagium vivum of smallpox,
and the controversies about diagnosis will not wholly dis-
appear imtil that comes about. Two recent communications
upon this subject are of interest. M. Funck, of Brussels,
describes what he calls the sporidium vaccinale, which he

September, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

299

thinks he recognizes in three stages. 1st, small, spherical,
highly refracting bodies of a green color, having slow move-
ments, and varying in size from 2 to 10 micromillimeters;
2nd, collections of smaller refracting spheres enclosed in a
sort of capsule; and 3d, morula masses 25 to 30 micromilli-
meters in size, which he thinks are spore cysts. He studies
the sporidium by the hanging drop method, in a warm,
moist chamber. The sporidia, he says, attach themselves to
the cover-slip, while the other elements fall toward the apex
of the drop. Funck also claims to cultivate the organism.
He spreads vaccine lymph on ordinary agar plates, which are
inoculated for 24 hours. The sporoblasts are, after incu-
bation, recognized under a low power. He picks these out
with a platinum needle hammered into a sort of spatula.
With this tool he transfers the sporoblasts to bouillon, and
the resulting emulsion, he says, produces typical vac.^inia
when inoculated into a calf. He gets the same organism
frMn the lesions of variola.

A second and more hopeful communication is that of
Copeman, who described in 1896 an organism that he was
able to cultivate from vaccine lymph, using the hen's egg as
a medium. His experiments failed frequently, and recently
he has come to the conclusion that his failures were due to
his working with eggs that were not fertile. He irioures
this now by incubating his eggs for a short time, asing only
those which prove fertile. He also used the collodion cap-
sule method of inoculation. Bouillon cultures of glyeerm-
ated vaccine enclosed in collodion capsules are placed m the
peritoneal cavity of the dog or the rabbit, and after 11 days
are removed, when stained films show zooglea masses, made
up apparently of spores. With the bouillon Copeinan pro-
duces vaccinia in the calf. Bouillon cultures in collodion
§acs, similarly inoculated, are put in plain bouillon test tubes
and kept in the thermostat for the same period. The con-
tents of these capsules, used as controls, do not produce
vaccinia in the calf.

I should like to use the lantern for a few illustrations of
smallpox cases recently observed in Mai-yland (Illustrations).

Dk. Smith, Minneapolis. — I would like to speak of the
results of the epidemic in our city. We have been passing
through an epidemic of this disease and this exliibition of
Dr. Porter's has been very interesting to me because one of
our physicians has been doing similar work. Ilis casts, how-
ever, were made of wax and were colored. They were pre-
sented to the University of Minnesota Medical Department
and are being used now to show the students the picture of
a disease they will not see in life.

We met with considerable difficulty at first in the diag-
nosis and the city had fifty cases before the health com-
missioner would recognize it. If it had not been for the
very efficient work of Dr. Bracken, the secretary of our State
Board of Health, the epidemic would have been much more
dangerous than it was. He worked night and day to sup-
press it and at times quarantined whole sections of the State.
We could trace the disease to two women wlio came to the
city infected. One of the peculiarities noticed at first was

the appearance of a bracelet around the wrists and of hard
nodules in the palm of the hands. We knew those were not
chicken-pox cases, and wherever we found itching or erup-
tion on the hands, we quarantined that person.

As to the question of vaccination

Closing Discussion of Dr. Porter's paper.

Dr. Poeteh. — In regard to the remark that it is left for
(he future to say whether we have had a modified form of
smallpox in this epidemic, I think one point may be men-
tioned to prove that this was not a modified form. The
different types of the disease were interchangeable even in
the same family — for instance in one family that I knew of,
the daughter had a mild attack of the discrete form. The
mother, who refused vaccination, contracted the disease and
died of the malignant hemorrhagic type, while her husband
developed the ordinary confluent form. Assuming that we
have a modified form, or an attenuated microorganism, it is
difficult to understand these cases.

In regard to the vaccination of cases that have recovered
from smallpox, I made that test in twenty-five cases and
did not get a take in any instance. I got two septic sores,
but they were not the typical vaccine sores. Other gentle-
men made the same experiments, and as far as I know all
failed, but of course it is not impossible that it might happen.

Adjournment.

June 3, 1901.

Fibrinous Bronchitis. Dr. Bettmann.

(Paper to appear in The American Journal of the Medical
Sciences).

Maggie Scott, colored, female, married, age 22, mother
of two children, labors normal, no history of tuberculosis;
menstrual history normal. The patient was admitted to the
Maternity Ward of the Johns Hopkins Hospital August 20,
1900, with the following history: At various times through-
out the past six years she has sufi'ered from attacks of cough,
pain, respiratory distress, and profuse expectoration of
branching casts usually in the autumn. Although she has
gradually emaciated during the past three years she has
been well during the intervals between the attacks, which
have had no relation to her pregnancies.

Her present attacks occurred thirteen days after normal
labor, and were characterized by a slight bronchitis, extreme
respiratory distress, a rise of temperature to 102°, and a
cough which was relieved by the expectoration of casts. She
had two similar attacks subsequently with an interval of
eleven days between them. She left the hospital in spite of
the protests of her physician four days after her last attack,
when she still had some slight evening temperature (rarely
101°). She remained in Baltimore three weeks and had simi-
lar attacks during that period, and two weeks later she died
in Virginia. No data as to the cause of death were obtain-
able. It should be added that the possibility of a puerperal
infection was excluded by the absence of local signs and the
general good condition of the patient. There was intense
dyspnoea and severe coughing during the attacks, with pain

300

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

in the left side of the chest. There were present rales of all
types, impaired resonance, and a small area of tubular
breathing in the right lower lobe during the first attack.
In the intervals between the first and second attacks an area
of impaired, resonance and impaired breath sounds were de-
tected in the left axillary region. There was no leucocy tosis ;
differential count normal; no albumin in the urine.

Casts. — During the two most severe attacks the patient
coughed up two casts 10 cm. long which showed branching
down to the 10th or 13th degree; other smaller casts were
coughed up in the interval. These, on cross section, showed
an outer laminated " skin," inclosing separate whirls and com-
plete cylinders. Air vesicles were seen throughout the casts.
Little intumescentia were seen at the ends of the finer
branchings. The use of Weigert's fibrin stain showed sur-
prisingly little fibrin distributed in the outer layer of the
casts. Hematoxylin and eosin stains showed mucin and a
substance taking the eosin stain deeply but not staining
with the Weigert stain. This substance, from its staining
reactions, did not seem to be mucin or fibrin but contained
the fibrillae that retained the fibrin stain. The cells are
mostly small mononuclear leucocytes; a few eosinophiles are
present; no polj'nuelears. There were no Charcot-Leyden
crystals. Throughout the casts were irregularly roimd
bodies, the size of a red blood corpuscle, staining with the
Weigert stain, with the tubercle stain and with eosin (eosin
methyl-blue method). These apparently had a double con-
toured shell, from which, in places, an inner granular and
vacuolated protoplasm seemed to have shrunk away. They
reminded one of the blastomyces which Gilchrist has de-
scribed in dermatitis. Baeteriologically the casts showed
staphylococci and streptococci on the outer side of the out-
side layer. Occasional organisms were seen in the inner
portion of the east. Cultures taken under antiseptic pre-
cautions from the interior of the cast showed the presence of
staphylococcus aureus, streptococcus pyogenes. There were
no pneumococei and no diphtheria bacilli.

An analysis was then given of Lebert's paper in Dentsches
Arch. klin. Med., 1869. To this was added an analysis of
all eases of fibrinous bronchitis in French, English and
German literature since 1869.

The author gro\iped the cases reviewed into 9 groups
for purposes of description: 1. and II. Chronic and acute
cases with expectoration of branching casts, 37 and 15 cases
respectively. III. Cases in which branching casts were not
expectorated but were found at autopsy, 6. IV. Cases in
which the casts expectorated showed no dichotomous brandl-
ings, 11. V. and VI. Expectoration of branching casts in
the course of organic heart disease and pulmonary tubercu-
losis, 10 and 14 cases respectively. VII. Expectoration of
small casts often not branching in asthma, 5 cases. VIII.
Formation of casts in bronchi following thoracentesis, 4
cases. IX. Poorly reported eases, 6.

The author demonstrated sections of casts in various
stains under the microscope as well as hardened specimens.

The Life History of Drepanidiiiiii. Herbert E. Durham and
the late Walter Myers. (Liverpool Yellow Fever Com-
mission.) .,

The smaller kind of toad found at Para, Brazil, was found
to be infested by endoglobular blood parasites. In all the
specimens examined two forms of parasite were foiind: (1)
with highly retractile protoplasm and granules, and of more
or less irregular shape, and (3) with pale i^rotoplasm and
elongate and fusiform in shape. The former correspond to
the " Dactylosoma " described by Labbe (Archives de Zoologie

Experimentale ? 1895 ) and the latter to the form

known as Drepanidium; both of these two forms were always
present, though in varying proportion. The highly refractile
form, when fully developed, is of an irregular amoeboid
shape or somewhat like a bent blunt club; segmentation or
sporulating forms in a fan-shaped arrangement are occasion-
ally met with, these often appeared to be referable to a tri-
partite division whereby each of three lobes gives origin to
three small bodies. We had no evidence that the adult re-
tractile forms ever leave the host-corj^uscle, the nucleus of
which, however, is dislocated. The pale form lies alongside
the nucleus of the corpuscle, which is not displaced. When
mature it leaves the corpuscle in specimens of shod living
blood, and swims freely with its narrower extremity forwards.
We are doubtful whether these forms ever leave the corpuscle
WITHIN the body of the toad, for in specimens of blood which
had been fixed with weakly sublimated saline solution and
eentrifngalized, no free forms could be foimd; thereby con-
trasting with similar specimens made without the fixing
agent in which hardly a single endoglobular individual could
be found. The multiplication of these forms takes place
chiefly in the liver (less in the spleen, and less still in sternal
marrow), where cysts about 10 /u in diameter containing
immature pale forms may be found in great abundance. The
mode of entry of these into individual red blood corpuscles
was not observed.

The toads were mostly infested by a species of tick: Ex-
amination of the contents of ticks showed a graduated series
of cysts up to about 60 ,u in diameter. The cysts consist of a
thin hyaline membrane (as seen in ruptured or empty speci-
mens) and fragmented protoplasmic masses lying within it;
usually also there are two or three larger protoplasmic masses
attached by bridles to the periphery. The small fragmented
masses correspond in appearance to small, actively motile
amoeboid bodies, found in the contents of the tick and the
plasma and corpuscles of the toad. Conditions suggestive of
conjugation of the free dreiJanidia have been seen in the tick,
where their movements are more rapid than in plain films of
toad's blood. The examination of cattle- and dog-ticks failed
to reveal cysts similar to those above mentioned, and we pre-
sumed that these were a stage of development of the blood
parasites of the toad. On this conception the cycle may be
compared to that of the malaria parasite in its development
in circulating blood, organs (marrow and spleen) and in the
anopheles group of gnats.

Septembee, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

301

Asexual cycle within blood corpuscle of toad (" Dacty-
losoma "').

Sexual cycle multiplication in organs (liver) of toad: leaves
blood corpuscles (" Drepanidium ") within tick: probable
conjugation resulting in formation of cysts: which give rise
to minute aniceboid spores.

Owing to the length of time of attachment of the tick
many stages are seen contemporaneously. From lack of ma-
terial it was not possible to make infection experiments upon
uninfected toads.

]VOTES ON ]y£W BOOKS.

The Hygiene of Transmissible Diseases: their Causation,
Modes of Dissemination and Methods of Prevention. By
A. C. Abbott, M. D., Professor of Hygiene and Bacteriology,
University of Pennsylvania. Third Edition. Revised and
Enlarged. Octavo, 351 pages, with numerous illustrations.
(Phihidclpliia and London: W. B. Saunders d C()mi)anij. Cloth,
$2.50 net.)

A review of the first edition of this excellent work appeared
in the Bulletin for March 1900. Since that time investigations
upon the modes of dissemination of certain of the specific
infections have been conspicuously active, and through them
much new light has been shed upon the transmission of dis-
eases and many novel suggestions have been made; especially
is this the case with regard to the roles of insects and rodents
as disseminating factors. Wherever practicable, these views
have been embodied and discussed in the present edition. The
resume of our latest knowledge of malarial fever is especially
good. In the treatment of the subject one feels that the
author has been hampered by what he had previously written,
and that the new and the old are not wholly harmonious. It
is to be hoped that in the next edition the state of our knowl-
edge of malarial disorders may be so complete as to justify
the rewriting of the whole section. The sections on Yellow
Fever, Plague and Dysentery are most valuable. The book
is in every way more satisfactory than was the first edition.

We notice one or two typographical errors, as e. g., on page
214 Koplic twice for Koplik, page 270 Clements for Clement, and
page 216 " periodic recurrence or paroxysms " for of parox-
y.sms.

Golden Rules of Hygiene. By F. J. Waldo, M. A., M. D.
(Cantab.), D. P. H., Barrister-at-Law. Golden Rule Series
No. X. {Bristol: John Wright cC- Co.)

This concise little book gives very sensible suggestions as
to Air, Water, Disposal of Refuse, Food and Infectious Dis-
eases. The rules are well arranged and easy of reference.

Essentials of Refraction and of Diseases of the Eye. By
Edward Jackson, A. M., M. D., Emeritus Professor of
Diseases of the Eye in the Philadelphia Polyclinic. Third
Edition, Revised and Enlarged. 12mo, 261 pages, 82 illus-
trations. {Philadelphia and London: W. B. Saunders c£ Co.,
1901. Cloth, $1.00 net.)

In this edition the work has been carefully revised and very
much enlarged, the contents being more complete and more
symmetrical than was possible in the earlier editions. The
injuries of the eye by traumation, and the ocular symptoms
and lesions of general diseases have now been given a consid-
eration proportioned to the great importance they assume
in the work of the general practitioner. There has been added

also an account of the application of the tests of vision
required in the army, navy and railway service.

This work has long since proved its usefulness to the begin-
ner in ophthalmic work, to the student, and to the busy
practitioner. The entire ground is covered, and the points
that most need careful elucidation are made clear and easy.

Burdett's Hospitals and Charities, 1901. Being the Year Book
of Philanthropy and the Hospital Annual. By Sir Henry
BuRDETT, K. C. B. {London: The Scientific Pre^s {Limited),
28 ii 29 Southampton Street, Strand, W. C; New York: Charles
C. Scribner's Sons.)

We are glad to welcome the twelfth year of the above pub-
lication. The manual is an invaluable aid to all persons who
have to do with charitable work, and the author has done
more to systematize hospital methods in this country and in
Europe than any other single person. The volume contains
much interesting reading, some of which commends itself
especially to one who lives in America and is familiar with the
freeness and liberality of the hospitals of the United States.
It is interesting to notice that there are seven hospitals in
London where the patients are required to supply their own
tea, sugar, and butter; thirty-three hospitals where patients
must supply a change of bed-linen; and nineteen hospitals
where patients are under the necessity of paying extra for
laundrj' work. At twenty-two hospitals patients are required
to provide more or less of the following articles: towels,
slippers, knife, fork and spoon, brush and comb, soap, plate,
cup and saucer; but it is gratifying to know that there are
twenty-two hospitals where patients are not required to fur-
nish anything. In the Provinces the number of hospitals
requiring miscellaneous articles to be supplied is very great.
It would seem in fact from reading the list, that poor patients
are obliged to supply an almost impossible number of requis-
ites. The author's very commendable reasons for furnishing
the above list are: " First of all, it is desirable, in the best
interests of the institutions and of those whom they treat,
that the in-jjatients should be required to provide nothing.
Discipline, cleanliness, and due regard to the circumstances
of the poor, all demand the abolition of the old-fashioned
practice of allowing patients to provide even personal linen,
much less to permit them to defray the cost of their own
washing. Secondly, any one who has a knowledge of hospital
accounts will readily recognize the considerable reduction
which there ought to be in the cost per bed, in the case of
hospitals which require the in-patients to supply themselves
with linen and groceries."

The book is admirably printed and well arranged. It is
surprising that it has been jJossible to .secure so much infor-
mation respecting American hospitals and training schools
for nurses.

Practical Surgery: A work for the General Practitioner. By
Nicholas Senn, M. D., Ph. D., LL. D., Professor of Surgery,
Rush Medical College, Chicago. Handsome octavo volume
of 1133 pages, with 650 illustrations, many in colors.
{Philadelphia and London: W. B. Saunders & Co., 1901. Cloth,
$6.00 net.)

Like all other practical works representing the surgical
methods of an operator who has had many years' experience
this book of Professor Senn is destined to be of great service
to the profession at large. It does not claim to be a systematic
treatise on surgery, but simply a statement of those things
which the every-day practitioner is likely to meet with in the
practice of surgery, either in the citj' or country. It contains
an account of Professor Senn's experience with gun-shot
wounds and injuries in the Spanish war and also in the

302

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 136.

Turkish war. His treatment of g-un-shot wounds is eminently
sensible. He speaks of the necessity of a complete immobili-
zation of the injured parts and of perfect antiseptic work in
connection with all first dressings. It is gratifying' to know
that by means of first aid packages and other modern devices,
the dreadful aspects of military surg^ery a hundred years ago
are completely chang'ed. He deplores the failure of laparot-
omy performed on the field for gun-shot wounds of the intes-
tines, although it is not strange that such surg'ery sho^tdd be
ineffectual.

The chapters on fracture are also extremelj' interesting,
especially his treatment of fractures of the hip. We are glad
to notice that he condemns absolutely the ambulatory treat-
ment of compound fractures.

At first glance it might seem .strange that he does not refer
to gall-bladder operations, operations for the relief of breast
cancer and operations for the removal of the Gesserian gang-
lion bvit it should not be forgotten that the treatise is for the
g'eneral practitioner and surgeon rather than for the surg-eon
who is in a position to do special operations. The operations
alluded to require a degree of expert knowledge which can
only be acquired after very long practice. Hence, wherever
practicable, it would seem extremely judicious to reserve such
specialized operations for specialists in private or general
hospitals who do them frequently.

The book is beautifully printed and well gotten up. A few
typographical errors are to be noticed, especially in the
names of individuals.

An interesting feature of the book is the attempt to empha-
size important points by the use of italics. Although one
is generally opposed to the wholesale use of italics in journal
articles, in the present instance their employment seems judi-
cious and helpful to the general reader.

Principles of Surgery: By N. Senn, M. D., Ph. D., LL. D.,
Professor of Surgery in Rush Medical College in affiliation
with the University of Chicago; Professional Lecturer on
Military Surgery in the University of Chicago; Attending
Surgeon to the Presbyterian Hospital; Surgeon-in-Chief to
St. Joseph's Hospital; Surgeon-General of Illinois; late
Lieutenant-Colonel of United States Volunteers and Chief
of the Operating Staff with the Army in the Field during
the Spanish-American War. Third Edition Thoroughly
Revised. With 230 wood engravings, half tones and
Colored illustrations., {Philadelphia and Chicago: F. A. Davis
Company, PuMishers, 1901.)

This work is a pioneer in its class in this country. Like
the other writings which have come to us from the author,
it shows a complete mastery of the methods of imparting
interest to dilEcult subjects.

The title might just as well have been "Surgical Pathology "
for this is the main feature of the work, which one might
infer from the title " Principles of Surgery." Practical details
in treatment are not wanting by any means. They are terse
as a rule and where diagrams can take the place of wordy
details they are inserted. The illustrations are numerous
and clear, the skiagraphs making a valuable addition to a
work on practical surgery.

Usually the author takes the broadest scientific view of the
matter and gives us the most recent knowledge on all subjects
with which he deals. After describing erysipelas at some
length he states very positively " the streptococcus of ery-
sipelas never produces suppuration." It is on bone tubercu-
losis that his clearing out is of i>articular value. He is liberal
in his views, not holding us fast to any one line of thought
unless there is unmistakable scientific proof for his way of
thinking. Owing to the arrangement of the subjects it is

difficult to locate the practical surgical details until after
having read the entire book.

Some surgical points on bone svirgery are to be found under
osteomyelitis, others under tuberculosis of bone or joints;
again others under abscess.

The treatment of paronychia and tendo-vaginitis is described
under suppuration. Under healing of wounds is given what he
has to saj' on technique and sutures. After exhorting to
absolute asepsis, the author deals with haemostasis, suturing
and physiological rest. He deals with regeneration of different
tissues, describes tenorrhaphy, nerve suture and healing of
T^'ounds of organs.

Degeneration is as thoroughly described as in text-books
on pathology.

As infiammation is divided into acute and chronic forms, so
is suppuration described as acute and chronic.

The pyogenic organisms and all other microorganisms
known to the surgeon are thoroughly described along with
something of the history of their discovery.

There are many little points valuable to the practicing
physician which are only found after careful reading. The
significance of pain is described under inflammation. It is
made of diagnostic value in periostitis and syphilitic bone
disease. ,

Inflammation, one of the most difiicult subjects to treat, is
very nicely dealt with from both the scientific and practical
sides. Senn states that " inflammation is always caused by the
presence of one or more kinds of pathogenic microbes " and
must be sharply distinguished from the regenerative processes.
The ti'eatment of the subject of ulceration is clearer and more
practical than in most text-books on surgery. Senn allows for
varying local and general conditions, tissues involved and
microorganisms present in the classification of ulcers. He
thinks that all ulcers are caused and maintained by pathogenic
microorganisms.

The treatment of the subject " tuberculosis " is excellent.
It is most comprehensive and, considering the limits of the
book, it is very thorough. One of the chief characteristics
of the book is the direct manner in which the lessons are
taught.

Senn's book is a natural outgrowth of the times. It comes
at a transitional iJeriod for students who are learning to
combine the science and practice of medicine more intelligently
than in former days. It is a book which should be at the

hand of every surgeon.

S. M. C.

Atlas of the Nervous System, including an Epitome of the
Anatomy, Pathology, and Treatment. By Dr. Chkistfeied
Jakob. With a preface by Prof. Ad. v. Stkumpell,
Edited by Edward D. Fisher, M D. With 113 Colored
Lithographic Figures and 139 other Illustrations, many of
them in Colors. (^Philadelphia and London: Vf. B. Suund;rs
& Co., 1901.)

The present Atlas is designed to give students and physi-
cians an adequate conception of the relations of various parts
of the nervous system to each other. The illustrations are
unusually good and some of them are extremely graphic.
Those relating especially to the cortex of the brain are works
of art. The principal value of the book, of course, is in its
appeal to the eye, and the endeavor which it successfully
makes to illustrate adequately the subject represented. The
portion of the book which relates to general pathology and
treatment is rather disappointing, because of the great brevity
which is necessary from an effort to compress the material
into the space allowed. The book, however, is creditable in
every respect. It is well printed and attractively bound.

Septembee, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

303

A System of Physiologic Therapeutics. A practical exposition
of the methods, other than drug'-giving, useful in the
treatment of the sick. Edited by Solomon Soi.is Cohen,
A. M., JI. D., Professor of Medicine in the Philadelphia
Polyclinic, etc. Vol. II. Electrotherapy. By Geoege W.
Jacobt, M. D., Consulting Neurologist to the German
Hospital, New York City, etc. In two Books, Book II:
Diagnosis, Therapeutics. Illustrated. {PiibUshcd 6;/ P.
Bkikiston'n Son <£ Co., 1012 Walnut St., FliiUidiiphm, Pa.
Price eleven vohtmes, $22 net.)

This volume, like all other honestly written books on electro-
therapy, is in some respects disappointing. The gist of it
seems to be that electricity, after its use as a diagnostic agent
is eliminated, is mainly serviceable by way of mental sugges-
tion and for its psj-chic effect. The sections of the work which
treat of electrophysiology and electroi^athology and of electro-
diagnosis and electroprognosis, seem especially valuable, and
are worthy of great praise for their clearness and conciseness.
Jlethods of examination are carefully given and charts and
diagrams render very clear the proper points for the electri-
zation of muscles and groups of muscles in every part of the
body.

'\Then we come to the sections on electrotherapy we learn
that electricity acts through a combination of exciting electro-
tonic, chemical (and electrolytic) cataphoric and psychic or
suggestive actions, and that " how great an effect is to be
ascribed to each individual action has not been and cannot be
demonstrated " . . . " That however, psjxhic influence does
form a very large part of the therapeutically beneiicial action
of electricity is undoubted, because the channels through which
it may act are manifold." All the other effects may " abide "
but the greatest of these is the psychic or suggestive effect
of electricity. This confession helps to explain why electricity
has invariably been the right hand of the quack and charlatan,
but it also tends to discourage the student of medicine who
has lived in hope that, sooner or later, order in electrothera-
peutics would emerge from chaos, and electricity as a remedy

for the cure of disease, would take a fixed and dependable
place in the medical armamentarium.

The book, as a whole, is a discriminating one and must do
good by placing electrotherapy upon a less pretentious and
more scientific basis. It should be diligently studied by all
who use electricity as a therapeutic agent.

The American Illustrated Medical Dictionary. A new and
complete Dictionary of the terms used in Medicine, Sur-
gery, Dentistry, Pharmacy, Chemistry and Kindred Branch-
es, ^vith their pronunciation, derivation and definition,
including much collateral information of an encyclopedic
character. By W. A. Newman Dorland, A. M., M. D., Fellow
American Academy of Medicine. With numerous illustra-
tions and 24 colored plates. (PliiladelpIiUi and London: W. B.
Saunders <i Company, 1000.)

In shape, size, binding and typography this volume is all that
can be desired for convenience and handy reference. The
print is compact and the sizes of type are so well adjusted
to each other, the page does not fatigue the eye. The binding
in limp leather renders the book easy to handle. The defini-
tions in some instances are open to criticism, e. g. " Paranoia,
Mental aberration or eccentricity with perversion of the will,
in pronounced cases it is a form of insanity." As a matter of
fact paranoia is a form of mental disease and characterized by
systematized delusions arising primarily, that is without ante-
cedent excitement or depression. The definition of B. aeroge-
nes Capsulatus is also faulty, " a pathogenic form from the
blood-vessels in a case of thoracic aneurism." Whatever may
have been the disease in which this bacillus was first found it
has been met with since in many other situations besides
the blood of a thoracic aneurism.

There are also some omissions, as e. g.. Dementia precox
cannot be found under the head of dementia.

The illustrations are good and many of them give valuable
aid to the text. The book can be commended as convenient
and useful.

STUDIES IN TYPHOID FEVER

SERIES I-II-III.

The papers on Typhoid Fever, edited by Professor William Osier, M. D., and printed in Volumes IV, V and VIII of
The Johns Hopkins Hospital Reports have been brought together, and bound in cloth.

The price is $5.00 per copy. Only a few copies of the volume are on sale. Those wishing to purchase should address
their orders to the Johns Hopkins Peess, Baltimore, Makyland.

304

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 126.

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Report on Typhoid Fever.

By WiLUAM OsLER, M. D.. with additional papers by W. S. Thayer, M. D..
and J. Hewetsox. M. t).

Report in Neurology.

Dementia Paralytica In the Negro Kaee: Studies In the Histology of the
Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic
Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The
Intrinsic Nerves of the Submaxillary Gland of Mtis nint^culu^ ; The
Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements
of the Pituitary Gland. By He.vrt J. Berklet. M. D.

Report in Snrgrery.

The Results of Operations for the Cure of Cancer of the Breast, from
June, 1889, to January, 1S94. By W. S. Halsted, M. D.

Report in Gynecology.

Hydrosalpinx, with a report of twenty-seven cases: Post-Operative Septic
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Report in Pntliolosy.

Declduoma Mallgnum. By J. Wbitridqe Williams, M. D.

Volume V. 480 pages, with 32 charts and illustrations.

CONTENTS;

The Malarial Fevers of Baltimore. By W. S. Thayer. M. D.. and J. Hewet-

SON, M. D.
A Study of some Fatal Cases of Malaria. By Lewellys F. Barker. M. B.

Stndies in Typlioid Fever.

By William Osler, M. D.. with additional papers by G. Blumer, M. D.,
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Volume VI. 414 pages, with 79 plates and figures.

Report in Nenrology,

Studies on the Lesions produced by the Action of Certain Poisons on the
Cortical Nerve Ceil (Studies Nos. I to V). By Henry J. Berklev. M. D.

Introducti" .—Recent Literature on the Pathology of Diseases of the Brain
by tne Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Exper-
imental Lesions produced by Chronic Alcoholic I'oisoning (Ethyl Alco-
liol). 2. Experimental Lesions produced by Acute Alcoliolic Poisoning
(Ethyl Alcohol); Part II. — Serum Poisoning.— Experimental Lesions In-
duced by the Action of the Dog's Serum on the Cortical Nerve Ceil;
Part HI. — Ricin Poisoning. — Experimental Lesions induced by Acute
Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin
Poisoning: Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical
Nerve Ceil produced by the Toxine of Experimental Rabies; Part V. —
Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from
the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal
Apparatus; Asthenic Bulbar I'araiysis. By Henry J. Berkley, M. D.

Report in Patliology.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By

Thomas S. Cullen. M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death. Probable

Migration of Ovum and Spermatozoa. By Thomas S. Cullen., M. B., ami

G. L. WiLKiNs. M. D.
Adeno-Myoma Uteri DiCfusum Benignum. By Thomas S. Cdllen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of

Infants. By William D. Booker. M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flejner, M. D.

Volume VII. 537 pages with illustrations.

L A Critical Review of Seventeen Hundred Cases of Abdominal Section
from the standpoint of Intraperitoneal Drainage. By J. G. Clark,
M. D.
n. The Etiology and Structure of true Vaginal Cysts. By James Ernest
Stokes. M. D.

A Review of the Pathology of Superficial Burns, with a Contribution
to our Knowledge of the Pathological Changes in the Organs In cases
of rapidly fatal burns. By Charles Russell Bardeen, M. D.
IV. The Origin. Growth and Fate of the Corpus Luteum. By J. G.
Clark. M. D.
V. The Results of Operations for the Cure of Inguinal Hernia. By
Joseph C. Bloodgood, M. D.

III.

Volume VIII. 552 pages with illustrations.

On the role of Insects. Arachnids, and Myriapods as carriers In the spread
of Bacterial and Parasitic Diseases of Man and Animals. By Georqe
H. F. NUTTALL, M. D., Ph. D.

Studies in Typlioid Fever.

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Cushino. M. D.. J. F. Mitchell, M. D., c. N. I!. Cajiac. M. D.. n. B. Gwyn,
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Volume IX.
trations.

1060 pages, 66 plates and 210 other Illus-

Contribntions to tlie Science of Medicine.

Dedicated by his Pupils to William Henry Welch, on the twenty-fifth anniversary
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Volume X. (Nos. 1-2 now in press.)

structure of the Malarial Parasites. Plate I. By Jessk W. Lazkar, M.D.

The liacteriology of Cystitis, Pyelitis and Pyelonephritis in Women, with a Consideration
of the Accessory EtioloKical Factors in these Conditions, and of the Various Chemical
and Microscopical Questions Involved- By Tuomas K. Bkown. M.D.

Cases of Infection with Strongyloides Intestinalis. (First Keported Occurrence in North
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volume of 400 pages. Price, in paper, $3.00.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice;
abstracts of papers read and other proceedings of the Medical Society of the Hospital,
reports of lectures, and other matters of general interest in connection witli the
work of the Hospital. It is issued monthly. Volume XII is now in progress. The
subscription price 13 $1.00 per year. The set of twelve volumes will be sold for
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Orders should be addressed to

The Johns Hopkins Press, Baltimore, Md.

The Johns Hophius Hospital BuUetins are ismcd monthly. They are printed hy TBE FRIEDENWALD CO., Baltimore. Sinole eopies may be procured from
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PRESS, BALTIMORE single copies will be sent by mail for fifteen cents each.

BULLETIN

THE JOHNS HOPKINS HOSPITAL

Vol. XII -No. 127.]

BALTIMORE, OCTOBER, 1901.

[Price, 15 Cents.

CONTENTS.

PAGE

Carcinoma of the Male Breast. By Louis M. Warfield, M. D., . 305
Report of a Case of Carcinoma Diagnosed by Means of Paracentesis
Abdominis; with Some Remarks on the Diagnostic Value of
Examinations of Serous Eflfusions. By Walter Ralph Steiser,
A.M., M. D,, , . . 310

A Case of Primary Adeno-Carcinoma of the Fallopian Tube. By

Elizabeth Hurdon, M. D. 315

Lipo-Myoma of the Uterus. By J. H. Mason Knox, Jr., Ph.D.,

M. D., 318

Chorea with Embolism of Central Artery of Retina. A short Review
of the Embolic Theory of Chorea. By Henry M. Thomas,
M. D., 321

Volvulus of Meckel's Diverticulum, with Recovery after Operation.

By William J. Taylor, M. D., . . , 336

OAEOINOMA OF THE MALE BREAST.*

By Louis M. Wabfield, M. D.,

House Medical Officer, The Johns Hopkins Hospital.

Although carcinoma of the male breast is not a very
uncommon occurrence, it is of snfRcient rarity to justify a
few remarks on the subject with a review of the eases pub-
lished in the literature in the past ten years.

Naturally a number of explanations have been offered to
account for the relative rarity of this condition in men as
compared with women, and the one most generally accepted
is that it is due to the inherent difference in the function of
the gland in the two sexes. In the first place the female
mamma is more apt to be injured for obvious reasons, and
in the second place it passes through a series of changes
tending to make it susceptible to new growths of all kinds.
Up to the time of puberty the gland is quite similar in the
two sexes, but from that time the course of one is, if not re-
gressive, at least stationary, with a poor blood supply, while in
that of the other there is growth of all the ducts and acini
with consequent greater vascularity. Then, too, at every
pregnancy the breast proper proliferates, the gland functions
during lactation, and after the child is weaned the mamma
goes through a series of regressive changes, becoming more
and more fibrous, until after the menopause, very little of the
true gland tis.sue remains. However, carcinoma of the breast
in both sexes has its origin in the gland epithelium, whatever
view one holds as to its etiology, and it is a well known fact

*Read before the Johns Hopkins Hospital Medical Society, March 4,
1901.

that a growth may exist as a small, painless nodule for years,
and suddenly take on malignant characters. This Imbert,'
thinks is due to the rupture of the surrounding capsule, thus
giving an exit for the further growth and invasion of the
tumor cells.

According to Elinscheff," the first man who recognized a
mammary cancer in the male breast, was Thorn. Bartholinus
(1616-1G80). Then later J. Muratt and Gottfried Bidloe,
Ijoth of whom lived in the 18th century, saw and described
cancers of the male breasts. The literature of the present
dates from Poirier's' thesis (1883), and this together with
Schuchardt's careful analyses in the " Archiv fiir Chir-
urgie " ' form the chief sources of our knowledge of this
condition.

Up to 1890 Schuchardt had collected from every source
and tabulated 472 cases of carcinoma of the male breast. He
carefully reviewed all the literature and made elaborate sta-
tistical researches, particularly with regard to the relative
frequency of occurrence in the sexes and the relation of
deaths due to this disease per 1000 of population in the large
cities of Europe. These statistics are so full that I shall
not review them, as the original articles are readily obtained.
Williams" in 1889 reported 100 cases, but as he did not
give the sources of his statistics, it is probable as Schuchardt
remarks, that some cases were reported twice.

I have collected up to the present time the cases reported

306

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

since 1890. I could find but 33 cases. To these I shall add
5 cases reported for the first time, 4 occurring in the Johns
Hopkins Hospital, and 1 case I observed with Dr. T. P.
Waring, of Savannah, Ga.

As to the relative frequency of this affection in the two
sexes, statistics vary at times considerably. Thus, Schuchardt
gives percentages from 1.6 to 8.4, obtained from various
clinics. Bryant says cancer in the female is 100 times as
frequent as in the male. Williams found it 117 times as
frequent. In this hospital, between the years 1888 and 1901,
there were admitted, on the surgical side, 307 cases of cancer
of the breast, of which 3 were in males. 1 case was admitted
to the medical wards. In St. Thomas' Hospital Reports
(England) for the years 1891-1899 inclusive, there were 287
cases of cancer of the breast, 2 of which occurred in males.

Age. — In my series of cases the age of the patients was
given in 36 cases. The majority, 25, occurred between the
ages of 40 and 70. The youngest was 12 years (Blodgetf),
the oldest 91 years (Lunn '). The greatest number occurring
in any one decade was 13 in the 7th decade. This is some-
what later than most statistics give, the 5th and 6th decades
seeming to be the time when cancer is most prone to occur.

Lmqfh of time the tumor was noticed. — The longest time
was 35 years (Owens and Eisendrath '). The shortest time
2 weeks (Moore*). The former was the case of a merchant
aet. 56, who was seen in 1898. Since 1863 he had noticed
a slight depression of his right nipple, and a small swelling,
the size of a pea, in the breast. This lump did not increase
in size until 1897, when a small scab formed on the nipple,
which, when removed, left a bleeding surface. No history
of traiima. From that time the tumor steadily increased in
size. In the other case there was a history of a blow 4
months before patient was seen. Six weeks after he was struck
on the breast, a small painless lump appeared in the right
breast. This gradually increased in size. At operation the
whole breast was removed and the microscopical examination
showed it to be a carcinoma.

Affected breast. — Either breast may be affected indiffer-
ently. Some statistics show that the left breast is more
often the seat of tumor, others the right breast. Thus in
Sengensse's paper he gives the following: Left breast, 17
out of 30 cases (Horteloup); 23 out of 37 cases (Poirier). In
Williams' cases out of 71 there were 38 in which the right
breast was affected, and Imbert '° gives 64 on the right side
to 48 on the left. In my 37 cases, 18 occurred in the right
breast and 18 in the left. In one case (Sinha") it was not
stated which side was affected.

Trauma. — Out of the 37 cases, in 8 cases there was a defi-
nite history of injury to the breast at some time previous to
the development of the tumor. No history in 4 and in 25 no
statement was made as to trauma. Two cases were apparently
caused by the irritation of constant friction. One, a shoe-
maker, pet. 91, who noticed that his braces rubbed his breast
and made it tender (Lunn). and the other a patient, set. 70.
with a similar history (MacLaren "). One case (Imbert ")
was thought to have developed cancer from the wearing of a

heavy watch over the right nipple. Sclnichardt gives 25 out
of 219 cases due to contusion or other mechanical cause.

Imbert " says that he often found in those males who have
cancer there is abnormal development of the breasts. In the
case he reports the patients' breasts were much larger than
normal. He thinks there is a relation between hypertrophied
breasts and cancer. In none of the other cases was any men-
tion made of enlargement of the breasts other than that due
to the tiimor itself.

Pain. — Pain was not a prominent symptom in the cases. It
was noted only 9 times. In several it was of a lancinating
character, and in one case described as gnawing. In 5 cases
it was stated that there was no pain. I think we might
assume that where pain was not a symptom nothing was said
about it, and we can then take the remaining cases, 23 in
number, making 28 cases in which there was no pain.

Ulceration. — Ulceration was given in 13 of my cases. In
Schuchardt's series of 219 cases, in 70 it was stated whether
or not ulceration occurred, ulceration being present in 61
cases. In nearly every case where the tumor had remained
latent for a long time, some irritation caused its rapid enlarge-
ment with, at times, ulceration. Imbert says that ulceration
is commonly preceded by the tumor's becoming adherent to
the skin. This is thinned, becomes purple and enlarged veins
are seen upon the surface. This is illustrated in all the cases
reported that ulcerated. Those cases in which the skin over
the tumor was described as being thin, piirplish, etc., were
undoubtedly seen soon before the ulceration of the tumor.

Retraction of nipple. — Retraction of the nipple was noted
in 12 cases. In 18 cases the nipple was involved. In one
case the nipple was totally destroyed (Case II), in another
case only part was gone (Mussey").

Discharge from nipple. — This was noted once. In 91 of
Williams' cases there was discharge in 7. It was sanious in
4, puriform in 2 and lactiform in one. In the female, Gross"
gives 15 out of 207 cases. In 3 cases the nipple was noted as
normal. In one of these cases (Powell"), although the tumor
was quite near the nipple, the latter was not involved.

Enlarged axillarj/ glands. — Out of 29 of the 37 cases the
axillary glands in 20 were enlarged and palpable. In one
case of 6 months standing, there were no glands felt. In
one that had been noticed for 9 months there was one gland
enlarged just at the anterior border of the axilla.

Macroscopical appearance. — There was nothing particularly
interesting in the gross appearance of the tumor. The crater-
like ulcer, with hard everted edges was described twice. The
tumor was always described as hard, at times as " stony " hard.
The size varied from a small lump that one could just feci,
to a large, ulcerating swelling the size of an orange.

Microscopical appearance. — The microscopical appearancrs
of the tumors in both sexes are quite similar. Thus far no
peculiarities of structure in the male cancers have been made
out. If we accept, for convenience, Billroth's classification of
carcinomata of the breast" into (1) acinous: (2) tubular; (3)
atrophic or scirrhus; (4) gelatinous, we find that the majority
of the male cancers are of the tubular type or, as he calls

OCTOBEB, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

307

them, carcinoma simplex. Mr. Marmaduke Sheild states
that the usual type of cancer of the male breast is the hard
spheroidal acinous variety. These would appear to be con-
tradictory statements, but on close examination the difference
is only in the nomenclature, which seems at present to be in
a chaotic state. In Williams' statistics " he found out of 100
cases 88 were of this type. 3 were classed as encephaloid;
tubular, not in the sense in which Billroth classifies tumors,
but the cyliudrical-celled duct cancers, G. He also found 3
squamous celled epitheliomata and one lie calls melanotic.
He states that the cyliudrical-celled duct cancer is relatively
more common in men than in women, while Luun,"" com-
menting on his case, remarks that this variety is very rare.

Of the 37 cases a microscopical examination was made in
26. Of tliese, 5 are called simply carcinomata. Of the
remaining 21 cases, 2 were cylindrical-celled duct cancers, 11
were classed as scirrhus cancers, the descriptions in the main
coinciding with that of Billroth's tubular variety or carcinoma
simplex, 7 alveolar (Billroth's acinous type). Three of these
were medullary cancers. Four of my cases examined under
the microscope were carcinomata simplices, although the
clinical history in one was very suggestive of a true scirrhus
(Case III).

Uperaiiun. — oi cases were operated on. Of the 3 remain-
ing, one (Murray") was too extensive for removal and the
other two. Case IV and one of Delacour's ™ cases, refused
operation. All of the patients operated on recovered from
tlie immediate eiiects of operation, except in the case reported
by Luun of the old man who, a few days after removal of the
tumor, died from " hypostatic congestion of the lungs." In
Mussey's '^. ease, 10 months after operation the patient was
quite well. The boy, 12 years old, (Blodgett) was well 5 years
after removal of the growth, which was a " typical carcinoma
and had iavaded all the visible gland tissue of the breast."
Boelhagen," who reported in his Dissertation 11 cases, followed
up the coui-se of events in 10. Three of these died. One died
3 years after operation, whether from a recurrence or not,
was not known. The other two died of recurrence, one
1 year after operation, the other 5 years after. In both of
tliese eases only a portion of the pectoralis major muscle was
removed, although in the former there was a macroscopical
growth in the substance of the muscle. The axilla was thor-
oughly dissected out and all glands removed in both cases.
Of my 5 cases the results are known in 4. Two diedj one
1^ years after removal (see Case III); the other 1 year
and 5 months after operation (see Case I). The other two
cases are at present well, but the operations were done com-
jiaratively recently (8 months and 3^ months ago), so nothing
can be inferred from them.

A most interesting case and one showing a not infrequent
sequela of cancer of the breast occurred in this hospital.
This case I shall report in full, as there was a careful autopsy
made, as well as microscopical sections of the original tumor
and metastases.

Case I.— W. L. C. B. Surg. I^To. 8117, xt. 47, was admitted
September 1.5, 1898, complaining of tumor of the left breast.

Family and past history have no bearing on the case. His
trouble he dated back 26 years, when he was 19 years old.
At that time he slipped on a fence and struck his breast.
About a month later he noticed a lump about the size of a
pea which gave him no pain or inconvenience, gradually in-
creasing in size, until 3 years before admission the tumor
took on a much more rapid growth and began to spread out.
In the summer of 1897 he accidentally cut it with a suspender
and noticed then that the growth was flattened out and about
the size of a silver dollar. The tumor steadily grew larger
and was sore when struck or handled roughly. In the winter
of 1897 he noticed for the first time a lump in the axilla the
size of end of thumb, which grew gradually to size of walnut
without giving him any pain. Pie saw also that the nipple
was being retracted and the skin over it was adherent. There
was no discharge from the nipple, when the tumor was cut;
only blood came from it. Patient had lost about 10 pounds
and felt that he was becoming weak.

Physical examination showed him to be a fairly well nour-
ished man. Occupying the nipple region and left areola
was a disc-like stony hard growth measuring 2.5 x 3 cm.,
with a slightly scalloped, distinctly elevated, sharply defined
margin. Iindiating out from this in skin were fine purplish
venules. The nipple was flattened out and retracted, and
the growth projected about 2 cm. above skin level. The skin
over most of the tumor was glistening and parchment like.
The axilla was a contracting metastasis, and 3 or 4 small
glands could be felt between it and the tumor. The pectoralis
major muscle seemed drawn together and flattened out,
although the tumor and metastases were movable on the deep
structures.

Complete operation, including excision of the glands in
the neck was done under ether Sept. 21. Axillary flap to
cover axilla and skin graft to cover chest wall. The skin
grafting took well and wound healed per primani, except for
a small slough at lower angle of axillary flap. Patient was
discharged well Oct. 2.

On Oct. 18 patient returned complaining of considerable
pain in the epigastrium and around the xiphoid, shooting
along costal margin to each side and coming on in paroxysms,
at times so severe that he was kept awake the greater part of
the night. His pain had no relation to the taking of food,
he had no nausea or vomiting, nor was there any marked loss
of appetite or strength. He complained of no pain in the
wound. The area where the slough was, was covered over
in great part by healthy granulations. He remained in the
hospital until Oct. 23, when he was discliarged improved,
although there was still some pain along the costal borders.

He returned again Nov. 3 complaining of similar pains and
stiff back. He remembered that a month before operation
he had had some pain in his lower right axilla, passing to
ensiform cartilage. Now, however, he was suffering from
girdle pains of a shooting but sometimes burning or aching
character, along the course of the 9th and 10th ribs. The
rigidity of his back was noticed for 2 weeks and was gradually
growing worse, so that he could not stand on his feet for long

308

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

nor could he stoop. On examination tliere was marked
rigidity of the spinal muscles, but no curvature or deviation
of the spine. At his own request he was discharged Nov. 5.

Again patient returned Feb. 6, 1899, complaining of the
girdle pains and trouble with his bladder. The attacks of
pain would come on in acute paroxysms, forcing patient to
double up with knees on chest.

Xow began the onset of his paraplegia, with stiffness in
the left knee and a feeling in the soles of his feet as if he were
walking on cotton.

On examination there was seen prominence of the 6th to
9th dorsal vertebrae with a small, red fluctuating, very painful
mass about the size of an almond at the level of the 8th spine.

Patient now became gradually worse. He had dribbling of
urine from an overdistended bladder and was troubled with
priapism. It was necessary constantly to catheterize him.
There was almost complete paresis of his legs which became
complete shortly before death. There was also some dulling
of sensation to pain and touch over lower legs anteriorly.
His pain was so intense that chloroform was constantly
administered. The prominence of the dorsal spines became
more marked and there was also distinct enlargement of the
spines.

Patient gradually sank. He became delirious and coprolalic.
At no time were his arms affected. The deep reflexes in his
legs which had at the onset been present with later develop-
ment of ankle clonus, were completely lost. Bedsores de-
veloped over sacrum and heels and he died February 37,
1899. At autopsy there were no metastases to the internal
organs, but portions of the sternum, ribs and vertebra; were
the seats of metastatic deposits. These growths filled the
interior of the bone, leaving only a surrounding thin shell of
bone, and on section were composed of dark purplish masses
in which spicules of bone were seen. The consistency was
semifluid. The spinal cord was removed and revealed on
the anterior floor of the canal a mass directly over the 7th
dorsal centrum. This mass was somewhat saddle-shaped,
measuring 3 cm. long and 1.5 cm. broad, extending almost
across the canal, projecting into it and causing a well marked
compression of the cord. There were several other small
nodules above and below this projecting into the canal, but
they probably exerted no pressure on the cord.

At the point where the tumor encroached on the cord there
was a definite compression with softening and narrowing
antero-posteriorly to about one-half thickness of adjoining
portion.

Microscopical sections were made from the original tumor,
from a nodule in one of the ribs, from the mass along the
spine, axillary and bronchial glands and from the mass
projecting into the spinal canal. Section of the breast shows
a tumor composed to large extent of connective-tissue stroma
with the tumor cells scattered in groups here and there.
Some areas show spaces lined by one or more rows of epithe-
lial cells which appear as cross sections of tubes having defi-
nite lumina. In other areas are strands of cells, while in
other parts dense masses of cells are seen which have in

many places shrunk away from the surrounding connective-
tissue wall. In some parts of the sections are seen large
masses of cells having the typical vesicular nuclei and rela-
tively large amount of protoplasm with very little connective-
tissue stroma. Everywhere, especially at periphery of tumor,
is seen round-cell infiltration. Sections through the pectoral
fascia and muscle show the former is infiltrated with the
tumor cells but the latter contains none.

Several axillary glands were studied and metastases were
found in some. Sections from a bronchial gland show cells
similar to those of the primary tumor arranged in acinous
forms. There is very little connective-tissue stroma. At the
periphery of the nodule the tumor cells can be seen infil-
trating the gland substance.

Sections of the marrow of a rib and a diseased vertebra;
and from the mass along the spines show dense infiltration
with the tumor cells.

A section from the growth in canal is seen to be composed
entirely of cells similar to, but smaller than, the original
tumor cells, and connective tissue strands separating these
cells into alveolar-like spaces. Microscopical diagnosis, car-
cinoma simplex.

Case II.--D. M., Surg. No. 10,731, ast. 71, admitted July
29, 1900, complaining of swelling of breast. Family and
past history negative. 16 months before admission he noticed
a lump on the right nipple which grew to the size of a straw-
berry, which was removed with cancer paste and he thought
himself cured; 2 months later the growth returned and pro-
gressively increased in size. He suffered with stinging pain
which kept him awake at night. Since his illness he had
lost 40 pounds in weight.

Physical examination showed patient to be a large, cor-
pulent man. Occupying region of right breast was a tumor
])rojecting 4 cm. above the chest wall, oval in shape 5x7 cm.,
with ulcerated surface and having a foul odor. The tumor
completely surrounded the nipple area and the nipple itself
had disappeared. Skin around it was tense and red, tumor
was not very hard or tender and was not adherent to under-
lying structure. Enlarged glands in axilla. Operation was
performed consisting of complete removal of the breast to-
gether with both pectoral muscles and a thorough dissection
and removal of the glands in the axilla and lower part of
neck. Patient made an uneventful recovery and is at pres-
ent well.

Sections from this tumor showed pictures quite similar to
those from Case I except that the tumor was more cellular.
Numerous mitotic figures were seen. One could surely say
from these sections that this tumor was of an exceedingly
malignant character. A section from the subjacent muscle
shows metastasis. Scattered throughout the tumor were
areas of hyaline degeneration of the cells. Several glands
were examined but no metastases were seen. Diagnosis:
Carcinoma simplex.

Case III.— P. S., Surg. No. 2628, a;t. 64, admitted Novem-
ber 14, 1893, complaining of swelling in left breast. 20 years
before lie sustained an injury to the breast which made it

October, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

309

always painful and tender. 5 years later he noticed a lump
near the nipple. During two weeks before admission the
swelling had increased rapidly and was tender on palpation.
The nipple was retracted and the skin over the tumor was
adherent to it and was dimpled and reddened. Nodule was
also adherent to fascia beneath. Tumor was situated in inner
and upper quadrant, measured 1.5 x 2.5 x 1.75 cm. Axillary
glands palpable.

Operation November 16. Breast with pectoralis major
muscle and axilla removed " en masse." Patient did well and
was discharged cured. He returned November 8, 1894, with
nodules over site of old scar and a few palpable glands over
right clavicle. These were removed under eocain and patient
discharged well. Patient did well until spring of 1895.
Then he gradually became weak and lost flesh and strength.
No pain or discomfort. He had no sensation of hunger and
ate very little. There was no dj'spncea, no pleural pain.
He became weaker and weaker and swallowing was almost
impossible. A distinct nodule was felt at this time in abdo-
men below costal margin. He died in May, 1895, 1 year and
(i months after operation. Autopsy showed carcinomatous
nodules in all the internal organs and in the lymph glands.
At the cardiac end of the stomach were a number of nodules.
Along the lesser curvature these had produced a stricture at
the cardiac orifice. No metastases to the peritoneum.

Sections from the tumor, glands and nodules removed from
the skin showed picture resembling tliat of Cases I and II.
The tumor cells were arranged in larger areas and there was
very little stroma substance in one section of a lymph gland.
Diagnosis: Carcinoma simplex.

Case IV. — Full notes of this case were lost. I am indebted
to Dr. Osier for the following facts. E. S., £et. 40, was
admitted to Ward C with a history of severe girdle pains and
]]ains in the legs for several months. When seen he was
rapidly becoming paraplegic, had a great deal of pain and
bad lost much weight. In the right breast he had a well
marked scirrhus tumor, which had not previously been recog-
Tiized, and which had given him no troiible. He refused
<iperation.

Case V. — I saw this case with Dr. Waring December 22,
1900. M. G., school teacher, ast. 50. For a number of years
be had been sulTering with a form of nervous dyspepsia.
Patient said he did not know how many years he had had a
lump in the left brea.«t. He thought he had injured the
breast before he noticed the tumor. It had begun to grow
rapidly in last few weeks. He had occasional sharp pains in
the breast and the tumor was very tender on manipulation.
The tumor was situated in upper and outer quadrant. The
nipple was retracted. The tumor was about the size of a
walnut and was firm, hard, and slightly nodular. It was
adherent to the skin but could be freely moved over the
deeper structures. No axillary glands palpable.

Operation consisted in removal of tumor and .subjacent pec-
toral fascia by an elliptical incision. The pectoral fascia
was infiltrated for some distance from tumor. Wound
sutured. Healing per primam. Patient is at present well.

Microscopical sections were made and examined. The pic-
tures corresponded to those seen in sections from Case I, so
that description will serve here. The pectoral fascia in this
ease was infiltrated with the new growth.

Finally, there is practically no difference between the con-
dition in the two sexes. The clinical symptoms are quite
similar, the pathological findings are alike and thus far the
microscopical examinations of the tumors removed from men
and women have shown no difference in structure.

All the varieties found in women are found in men, but
it appears that the atrophic scirrhus carcinoma is much more
common in women. The figures also show that in men the
nipple is more apt to be involved, possibly because the gland
is so small that any growth must of necessity be near enough
to the nipple eventually to cause its retraction. Ulceration
would appear to be more common in men, while discharge
from the nipple is relatively more frequently seen in women
(Gross, 15 out of 207 cases). Pain, while at all times a
variable symptom, is not so great in male as in female cancer
(Imbert), although it can be of an excruciating character as
seen in several cases reported in the literature.

It is interesting to note that in my first case, although
there were many metastases in the bones, none of the organs
were att'ected, whereas in another of my cases (Case III)
autopsy showed carcinomatous deposits in all the organs with
a nodule at the cardiac end of the stomach, causing stenosis
of the orifice. The bones in this case unfortunately could
not be examined but it is probable from the history that they
were free from metastases. In still another of my cases (Case
IV) the patient came to hospital complaining of girdle pains
in the legs which for several months had been severe. He was
rapidly becoming paraplegic and had lost much weight. He
did not know he had a tumor of the breast, which was found
on making the physical examination. It is within reason
to suppose that he had a condition similar to my Case I, with
metastases in bone but none in the internal organs.

References.

1. Imbert: Gaz. hebd. d. sc. med. de Montpellier, 1891;
xiii, 541.

2. Eliascheff, L.: Ueber Krebs der miinnlichen Brust-
driise. Wiirzburg, 1891.

3. Poirier, P.: Contribution a I'etude des tunieurs du sein
chez I'homme. These, Paris, 1883, 4. No. 379.

4. Schuchardt: Archives fiir klin. Chir. Bd. 31, Heft 1,
1884. Ibid. Bd. 32, Heft 2, 1885. Ibid. Bd. 41, S. 6-1.

5. Williams, Roger: Lancet, 1889, ii, 261, 310.

6. Blodgett, A. N.: Cancer of the Breast in a Child.
Boston M. & S. Jour., 1897, exxxvi, 611.

7. Lunn, J. R.: A Case of Cancer of the Breast in a
Man Aged 91. Tr. Path. Soc. Lond., 1896-97. xlviii, 247.

8. Owens, J. E., and Eisendrath, D. N.: Carcinoma of
Male Breast. Chicago Med. Rec. 1898, xv, 149-153.

9. Moore: Austral M. J., Melbourne, 1895 n. s.. xvii. 496.

10. Imbert: Loc. eit.

11. Sinha: Indian Med. Rec, Calcutta, 1896, x, 146.

310

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

13. MaeLaren: Maritime Med. N., Halifax, 1891, iii, 85.
13 and 14. Imbert: Loo. eit.

15. Mussey: Cincin. Lancet CI., 1893, n. s., xxx, 258.

16. Gross, W.: A Practical Treatise on Tumors of the
Mammary Gland, l^hnliracing their Histology, etc. New
York, 1880.

17. Powell: Care, of Male Breast. Wostm. IIosp. Rpts.,
Lond., 1890, vi, 95-97.

18. Handbuch der Praktischen Chirurgie. Stuttgart,
1900.

19. Williams: Loc. eit.

20. Lunn: Loc. eit.

21. Murray, F. W.: Care, of Male Breast. Ann. Surg.,
Phila., 1898, xxviii, 655.

22. Delacour, J. : Contribution a I'etude du cancer du sein
chez I'homme. Paris, 1894.

23. Mussey: Loc. eit.

24. Bollhagen, P.: Ueber Brustcarcinome beim Manne.
Gottingen, 1892.

25. Tliompson, J. p].: Seirrhus Cancer of the Breast in
a Male. Texas Clin., Dallas, 1898, i, 117.

Beach: Bost. M. & S. Jour., 1890, exxii, 474.

Buchanan: Glasgow M. J., 1893, xl, 149.

Ilodenpyl: Proc. N. Y. Path. Soc. (1889), 1890, 70.

Fi-iedrich, E.: Ueber Carcinoma mammffi virilis, nebst
Mitteilung eines Falles. Greifswald, 1893.

Robinson: Tr. Path. Soc, Lond., 1889-90, xli, 227.

Sengensse: Ann. de la Policl. de Bordeaux, 1805-6, iv,
278.

Guiteras, R.: N. Y. Med. J., 1898, Ixviii, 101.

REPORT OF A CASE OF CARCINOMA DIAGNOSED BY MEANS OF PARACENTESIS ABDOMINIS,
WITH SOME REMARKS ON THE DIAGNOSTIC VALUE OF EXAMINATIONS

OF SEROUS EFFUSIONS.

By Walter Ralph Steinee, A. M., M. D., Hartford, Conn.
Formerly House Medical Officer of the Johns Hopkins Hospital.

The following case is reported because of the accidental
method of diagnosis.

Fannie C, negro, aged 63 years (Hospital No. 25,015),
was admitted to the Johns Hopkins Hospital, December 15,
1899, complaining of pain and swelling of the stomacli.

Family history. — Negative.

Past history. — Measles and chicken-pox as a child. Small-
pox thirty-seven years ago, having contracted it during an
epidemic of this disease in Baltimore. About thirty years
prior to admission to hospital she had some ill-defined womb
trouble, for which she received treatment. Denied syphilis.
Was generally a moderate beer and whiskey drinker, l)ut at
times had drunk to excess.

Present illness. — During July and August, 1898, she
noticed her " stomach " would swell after eating but woidd
go down again in an liour or two. This continued daily until
about eight weeks ago when she observed the swelling did
not decrease in size but kept constantly growing larger.
About this time, also, she began to complain of sluirp pains
in the pit of her stomach. They would frequently radiate
to the back and obliged her to stop work. Since then she
had suffered a good deal from coughing and shortiu'ss of
breath. Both were aggravated ]>y exertion, so she had spent
most of her time in bed or sitting up in an easy chair.

For six weeks past she had had a burning dull jiain, from
umbilicus down to pelvis, just before micturition. Apjiar-
ently there was no increase in frequency or in the amount
of urine voided. She was, as a rule, constipated and fre-
quently had to take remedies for it.

For two weeks she had noted a slight white, non-irritating.

vaginal discharge — the first since her menopause, eigliteen
years ago.

Physical e.r ami nation. — The piatient was a well developed,
well nourished mulatto woman. There was no cyanosis, no
respiratory distress and no cough during examination. The
lips and mucous membranes were of good color. The tongue
was tremulous and coated with a thin white fur.

Thorax somewhat barrel shaped. Respiratory movements
fair and equal. Costal angle normal.

On palpation the vocal fremitus was diminished in the
lower right axilla and over the lower left lobe in the back.
It was absent over the lower right lobe behind. On percus-
sion the note was impaired where the vocal fremitus was
diminished and there was slight movable dulness in the right
front. Over the lower right back the note was quite dull.
On auscultation the breath sounds were enfeebled wliere the
note was impaired and fine and coarse moist rales were here
heard. The breath sounds M^ere absent on the lower right
back and the vocal resonance here had a nasal quality.

Heart not enlarged. A soft systolic murmur was heard
at the apex, which was not transmitted upwards or outwards.
The ]mlmonic second was somewhat accentuated. Pulse 94
to the minute, regular in force and rhythm, and of good
volume and tension. Arteries not thickened.

Ahdomen very much and symmetrically distended. The
veins in the lower quadrants were quite prominent and swol-
len. The costal and iliac grooves were absent. There was
marked bulging of the flank lines and also of the dependent
parts on changing position. On palpation fluctuation was
easily obtainable. On percussion there was dulness in the

October, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

311

dependent parts, with movable diilness when she changed
her position.

Extremities. — Feet and legs were very oedematous and
pitted easily on pressure.

On December 18 a vaginal examination was made by Dr.
Hunner with negative results. The note does not state
whether the ovaries w'ere palpated.

The day following, patient's abdomen was tapped, the
troehar being inserted in the median line, midway between
nmbilicus and symphysis pubis. 8000 ce. of a dull red fluid
were withdrawn (see Chart I. for this and subsequent tap-
pings). After the tapping Dr. Futcher made the following
note: " For the past two nights patient has had some rise of
temperature. On December 18, her temperature was 102°
at 8 p. m., and on December 19, at the same hour, it had
risen to 103.8°. She has had no distinct chill.

" The abdomen is still markedly distended. The costal and
iliac grooves are symmetrical. There is marked bulging in
the flanks. On percussion the note is tympanitic in the
elevated but flat in the dependent portions. There is still
considerable fluid in the abdomen and distinct movable dul-
ness is obtainable. The relative hepatic dulncss begins over
the middle of the sixth interspace, and the absolute over the
middle of the seventh interspace, and extends to a point 8..")
cm. below the costal margin in the mammary line. The total
extent of absolute dulness measures 14 cm. On palpation a
definite mass is felt, occupying the lower part of the epigastric
and the upper part of the umbilical regions. The fingers
can be distinctly placed below the margin of this mass, which
extends over to the right and becomes continuous with a
resistant mass in the lumbar region of the abdomen. From
this mass it is separated by a more or less distinct notch,
somewhat resembling the notch in the liver. The fingers
can be pressed in above the mass in the epigastrium. To the
left the outline of the mass is less distinctly made out, but it
appears to terminate at the junction of the upper quadrant of
tlie umbilical with the lumbar region. The surface of this
mass, as well as its lower border, is very nodular and rather
hard. To the right its margin is not definitely to be made
out. The lower margin of the tumor descends slightly on
deep inspiration but does not feel as if connected with the
liver. The mass is very freely movable in both vertical and
transverse directions. It seems to be separated from the
abdominal wall by a thin layer of fluid. After inflation of
the stomach, the mass becomes more prominent and descends
distinctly. Its lower margin is now well felt 4 cm. below
the umbilicus in the median line. The tumor is extremely
nodular; this is more marked than before distension. The
upper limit of stomach tympany begins at the sixth inter-
space on the parasternal line. The lower limit of stomach
tympany reaches 4 cm. below the umbilicus in the median
line, at the lower margin of the tumor. Over the tumor area
dull tympany is obtained on percussion. There is no definite
peristaltic wave to be made out. No definite glands palpable
in the supraclavicular fossse or in the episternal notch. The
axillary glands are not enlarged, nor are the inguinals especi-

ally increased in size." The rectal examination was practi-
cally negative.

On the next day Dr. McCrae described the tumor as an
almost continuous succession of nodular masses which were
best felt on deeper dipping. He made out the total extent
of these nuisses to be 21 cm., reaching from the right mam-
mary to the left parasternal line. No tumor was felt in the
costal angle or emerging from the left costal margin. Dr.
Osier described these distinct nodular masses as separate
from the stomach, which was palpable on infiation.

January 10. Patient's stools were exanuned for tubercle
bacilli with negative results. They had been very watery
and chocolate in color for some days previous. No excess of
fat was made out by microscopic examination.

Three days later a blood examination gave the following:
red blood corpuscles 5,608,000; white blood corpuscles 4400;
hcemoglobin 68 per cent.

A few days before January 31 she had complained of pain
in the right side and shortness of breath. On that day the
percussion note was flat over the right lung almost from apex
to base, in front and behind. The vocal fremitus was slightly
exaggerated below the right clavicle, but elsewhere it was
diminished. The breath sounds over the upper right front
had a slightly tubular, amphoric quality, and the voice sounds
throughout were somewhat diminished and of a distinct nasal
quality. There was appreciable movable dnlness over the
first interspace. The point of maximum cardiac impulse
was in the sixth interspace 11.5 cm. from the mid-sternal
line. The heart's action was rather rapid, and the rhythm
was suggestive of embryocardia. Later in the day the right
pleura was aspirated, the needle being inserted a little to the
left of the angle of the scapula, in the eighth interspace.
1550 ec. of a thin hoemorrhagic fluid were withdrawn (see
Chart II. for this and subsequent aspirations). The point of
maximum cardiac impulse as well as where the sounds were
best heard could not be well determined after this aspiration.
They seemed to be well within the measured spot given above.

Feb. 18. Blood examination. — Bed blood corpuscles 4,522,-
000; white blood corpuscles 14,000; haemoglobin 58 per cent.
Five days later she complained of passing a considerable
quantity of blood in her stools. From this time on her
condition gradually grew worse. On March 13 an emphy-
sematous condition of the abdominal w'all was noted, and the
oedema here and in the extremities was most marked. Two
weeks afterwards she began to have severe attacks of vomiting
and could retain nothing on her stomach. This was relieved
by tapping. Micturition now became somewhat difficult and
she was only able to void very small quantities of urine at
one time.

April 7. Blood exam.inaHon. — Red blood corpuscles 4,476,-
000; white blood corpuscles 10,000; haMnoglobin 60 per cent.
Differential count:

Polymorphonuclears 82.

Large mononuclears and Transitionals. . . . 7.5

Small mononuclears 10.

Eosinophiles 5

312

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 137.

About this time she began to expectorate very profusely.
The sputum was clear, watery and frothy in character, with
a slight whitish sediment. No tubercle bacilli were found
on examination.

On April 10, on putting the trochar through the canula,
after a tapping, a small piece of tissue, 5x1 mm., was noticed
at the end of the trochar. It was white in color and looked
very much like fibrin. Thinking, however, it might be of
some diagnostic import, we hardened it in alcohol and finally
imbedded it in celloidin. The sections were stained with
hasmatoxylin and eosin. Their examination will be later
mentioned.

The patient grew gradually weaker and became somewhat
emaciated. During her last month she was obliged to re-
main in bed. Dr. Futeher made the following note on May
22: "Patient's temperature has been gradually falling dur-
ing the past four days. This a. m. at eight it is 96. Pulse
is irregular and extremely weak, almost imperceptible, 25 to
the quarter. Owing to fulness and distension of the abdomen
it is practically impossible to make out the mass, which has
been felt, except in the epigastrium a sense of resistance is
encountered. The oedema of the abdominal walls is consid-
erable. There is flatness over the right lung as high as the
third interspace, above which the voice sounds are harsh and

exaggerated.

The respiratory murmur below is feeble, dis-
tant, and of a suggestive tuljular quality. The apex beat is
in the fifth interspace, 2 em. inside the mammary line. The
heart sounds are well heard at apex and base. There are no
endocardial murmurs. The second pulmonic is accentuated."

The week before her death she failed very raiiidly. She
died on May 27 at 7.15 a. m.

Urine. — On entrance the urine was dark amljer in color,
cloudy, 1025 in specific gravity, acid on reaction, negative for
sugar and albumen. There was a heavy, grayish, flocculent
precipitate. Microscopically a few hyaline and granular
casts, as well as many epithelial cells, red blood corpuscles,
white blood corpuscles, and mucous cylindroids. The bile
test was negative. The subsequent examinations did not
vary much from the above save that albumen was gener-
ally found as a trace.

Temperature. — This varied between 100° and normal till
December 18, when it rose to 102° (see Dr. Futcher's first
note. It fell to normal December 20 and ranged about as
before till January 7, when it rose to 101°. Then it varied
generally as before, but occasionally was subnormal till April
8. It rose on this day to 101.4°, but fell in two days and
remained as before until May 18. From this date on it was
subnormal.

CHART I.— EXAMINATIONS OF THE ASCITIC FLUID.

II.

III.

IV.

VI.

VII.

VIII.

IX.

XI.

XII.

XIII.

XIV.

Dec. 9.

.Ian. 7.

Jan. 19.

Feb. 7.

Feb. 27.

March 11.

March 20.

March 27.

April 3.

April 10.

April 18.

April 25.

May 5.

May 14.

Amouut . .

8000 cc.

6500 cc.

4000 + cc.

6800 CO.

6430 cc.

7000 cc.

7030 cc.

4800 cc.

10,000 cc.

8000 cc.

7030 cc.

7000 ce.

6400 cc.

.5000 cc.

Color and

character-

istics . . .

Dull red.

Reddish

Yellowish

Reddish

Amber,

Orange

Lemon

Reddish

yellow,

red,

yellow,

green.

cloudy.

yellow.

vellow.

yellow.

cloudy.

Reaction. .

Neutral.

Slightly

Neutral.

Alkaline.

Neutral.

Specific
gravity . .

alkaline.

1018

1019

1030

1017

1015

1014

1015

1014

101!)

....

Sediment .

Floccu-

Reddish

Slight

Red, with

Red.

lent.

black.

white.

fibrin
flakes.

Albumen .

2.2.5«

3.8%

2.h%

2.5%

3.5%

Present,
a'mt not
stated.

1.7«

Present,
am't not
stated.

Sugar

None.

0 C8 ' bcSS

600 o a o

■S.9

ffl

O •

0 O) C "3 ni

I- « S

«S

r SoS^a

S a-

3 .

Micro-

•a®
o >>

"■•SI'S S a

o g 3
0*0

u
o

•T3

a.
u

u
o
o

■a

U
O

■a

scopically

%i^

g-«0.°'3^

c«"
o o'a

5o;

.2 CO

o g3

ai di Q
30"

a o o
*- o o

to SI'-'

3ii
■S8

0) o

2o^

°S2

^ 8

" 3

-g

Soo.9'2-5

CO 3

>,3

:>.©

>,3

>>3

>.d

•^■3 p.

Nun
size f r
led bl
clear
many
occur

a 1)

0 «J
03""'

Is
0)

P Si

October, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

313

CHART II.— EXAMINATIONS OF THE PLEURAL EFFUSIONS.

Amount

Color and cbaractcr- ("

istics j

I
Reaction

Specilic gravity

Sediment

Albumen

Sugar

Microscopically

I.
January 31.

15.50 cc.

Yellow, cloudy
with flakes of
tibriu, colored
red.

Alkaline.

None visible.

None.

Many red blood
corpuscles.

11.
February 23.

ISOO ec.

Blood red,

cloudy.

Alkuliue.

1017
TUick red.

4.5%

None.

Many red blood
corpuscles.

III.
April 12.

600 cc.

Blood red,

cloudy.

Alkaline.

1010
None visible.

1.5«

None.

Many red blood
corpuscles.

Abstract of protocol. Anatomical diagnosis. — Carcinoma
of ovary. Secondary implantations on peritoneum. Involve-
ment of right pleura. Ascites and hydropericardium. Com-
pression of lung. Secondary nodules in liver, intestine, etc.
Obliteration of appendix by tumor mass. Myomata uteri.

Autopsy by Dr. MacCallum. Body of a large woman, 163
cm. in length. Great oedema of legs and abdominal walls;
well marked oedema of left hand.

Peritoneal cavity contains large quantities of smoky, turbid
fluid. Peritoneal layers are much thickened. Parietal peri-
toneum is roughened by a rather congested, semi-translucent,
new growth. There are small depressed areas here and there
resembling ulcers, the bases of which are smooth and clear;
the tissues dividing these ulcer-like places are shining and
scar-like in character.

Omentum drawn up into a firm mass over the level of the
transverse colon and forms a transverse group of hard nodules
which have a rather translucent appearance, and are studded
with opaque, yellowish masses. Intestinal coils not especi-
ally adherent but serous surfaces, as well as serous surfaces
of mesentery, are everywhere studded with nodular masses.
varying in size from pin point to size of a bean; these have
spots of opacity. There are a few adhesions between the
coils of intestine lying over the fundus of the uterus and the
bladder. The appendix is obscured in a firm mass of the
tumors. The under surface of the liver is bound by adhe-
sions to the stomach and transverse colon. There is great
thickening of the peritoneum over the under surface of the
liver. The upper surface of the liver is densely adherent to
the diaphragm.

Eight pleural cavity contains a large quantity of blood-
stained fluid.

Pericardivm contains a small amount of clear fluid. The
pericardial layers are smooth.

TAinijs. — The left pleural cavity contains a small amount i>f
fluid. The pleural surfaces are generally smooth. Over
pleura of upper lobe and upper portions of lower lobe there
can be felt and seen pearly white nodules of pin-head size.
The anterior portion of the left lung is air-containing.

There are two nodules in the anterior edge which have a
firm consistence but show no changes in color; similar nodules
at base of lower lobe. On section there can be felt through-
out tlie lung numerous, minute, firm nodules which are some-
what pigmented. These masses are oedematous and appar-
ently contain some alveolar exudate. Surface of the lung
has a rather salmon pink color and is quite moist. Bronchi
are somewhat congested; blood-vessels clear.

The right lung is very much compressed by pleural exudate
and occupies an area limited below to the level of the third
rib. The pleural layers exhibit the same nodular appearance
.described in peritoneal cavity. The lung is so much com-
pressed that the lobes are indistinguishable; the lung sub-
stance on section is, in general, air-containing and rather
leathery in consistence. The lower portion is soft and has
a grayish, opaque appearance. The bronchi and vessels are
much thickened and are very prominent over the whole cut
surface. There are no tumor nodules in the lung. The
costal pleura is very much thickened by the presence of
tumor nodules and has rather a hsemorrhagic appearance with
a ragged surface.

Spleen is bound down to diaphragm by old adhesions which
have the same translucent appearance as the nodules already
described. Weight 150 grms., measures 11 x 7 cm. Capsule
thickened and opaque. On section the Malpighian bodies
and the trabeculee are well seen. At hilus is a rather whitish
nodule, soft, and somewhat translucent, apparently part of
the tumor. Similar pin-head sized nodules occur adjacent
to the vessels in the pulp of the spleen. The spleen pulp
has a rather brownish red color. On stripping away dia-
phragm from liver the former is found to be studded with
tumor nodules which often correspond with nodules on the
surface of the liver.

Vagina normal.

On attempting to dissect apart the pelvic viscera neither
ovary can be correctly outlined. The Fallopian titles are
distended and congested and are partly imbedded in a mass
of tumor substance.

Uterus is involved from without by the tumor nodules.
Its wall also contains several small myomata.

Liver. — Weight 1400 grms. Measures 24 x 19 x 9 cm. The
upper surface is much roughened by the growth of tumor
nodules between it and the diaphragm. There are also
numerous superficial nodules. Similar nodules, reaching a
diameter of 2 cm., may also be found in the substance of the
liver; they are rounded, white and semi-translucent. The
liver, in general, shows evidences of chronic congestion.
There are some translucent nodules about pin-head size.

Kidneys. — These showed nothing, save that over the sur-
face of the right kidney a few opaque, rather yellowish
nodules were seen.

. I rfre;)a?s.— The left adrenal contains several yellowish
nodules which lie in the cortex.

Storri.ach. — There are tumor nodules in the outer wall of
the stomach but the mucosa is everywhere smooth.

314

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

Pancreas. — There are small nodules throughout the sur-
face of the pancreas, otherwise it is apparently normal.

Gre<d omentum. — The rolled up omentum forms a mass 31
cm. long and 6 cm. in diameter; this forms the largest and
firmest of the tumor nodules.

Mesenteric glands. — The mesenteric glands in general are
not much enlarged but apparently contain tumor nodules.

Intestines. — The mucosa of the whole intestinal tract is
apparently normal except for a few sub-mucous nodules in
the ileum; one of which seems to involve the mucosa. There
are also a few idcerated patches in the colon, probably due
to changes produced by the invasion of the tumor nodules.
The serous surfaces are everywhere thickly studded witli
nodules. In the position of the appendix there is an elon-
gated tumor mass, at the base of which there is a cavity
apparently lined with mucosa. This cavity cannot be further
traced into the tumor mass.

Baderiological examination. — The cultures from the peri-
toneal and pleural cavities were contaminated, but from the
heart's blood the streptococcus pyogenes was obtained. The
examination was otherwise negative.

Histological e.vamination. — The tumor is an adeno-carci-
noma with an irregular glandular structure, the epithelial
cells being arranged in several layers. Some nodules in the
liver are gland-like masses, very small and lined by one row
of cells; others show masses formed by cells making alveoli
in the stroma. The liver also shows extreme fatty degener-
ation. The lung shows well defined broncho-jmeuinonia and
anthracosis. Tlie kidney sections show moderate diffuse
connective-tissue growth and parenchymatous degeneration
of the epithelium. The sections from the intestines show
a sub-peritoneal tumor, as well as a nodule imbedded in the
muscular coat. In the subserous tissue well defined lym-
phatic spaces occur, filled with tumor cells. The spleen
shows evidence of chronic interstitial splenitis and contains
a well defined tumor nodule.

In considering the diagnosis of this case two diseases were
chiefly thought of, viz.: tuberculous peritonitis and carcinoma.
If the latter was the correct diagnosis it wa.s impossible to
conjecture the primary seat of the disease, as there were no
symptoms on the part of any of the abdominal organs. The
stomach or the ovaries seemed to be the most likely origin.

Numerous attempts were made to obtain a test breakfast,
but the patient strenuously objected to the passage of a
stomach tube, so this aid to diagnosis was consequently
unavailing. It is to be regretted that the tuberculin test
and animal inoculations with the serous fluid were not
resorted to. The age of the patient and the presence of a
vaginal discharge were in favor of the malignant nature of
the disease. The vaginal examination was negative. There
wa.s no emaciation until about one month before death. All
doubt as to the diagnosis, however, was dispelled when the
piece of tissue, removed during a tapping, was examined
microscopically.

During the past century the doctrine was stoutly main-
tained that cancer cells were characteristic: many claimed

to be able to diagnose a malignant tumor by examining the
cells in a serous effusion. This theory, nevertheless, gradu-
ally lost ground, till now but few believe in it.

Dock ' has made a valuable contribution to this subject and
has shown that similar cells are found in cancerous, tuber-
culous, and other effusions. He, Eieder," and Warthin,''
however, claim that the diagnosis of a malignant growth
may be made by the presence of many cells in serous effusions
showing mitoses. These mitoses may be typical or atypical
in type. The distinction is a quantitative and not a quali-
tative one.

In our ease, though centrifugalized specimens were fre-
quently examined and a number of stained specimens of the
dried sediment made, yet in no instance were such cells seen.
On two occasions (see Chart I.) large mononuclear cells were
observed, but through Dock's studies, we know they can be
found in ordinary serous effusions. They were probably
endothelial in origin.

In fixing the sediment on tlie slides, besides the usual
means em|)loyed, lialirenberg' has used the following nu'thod:
"After decanting the supernatant fluid, the addition of
alcohol was followed 1)y the changing of the more or less
ropy sediment into a firm mass resembling coaguluni. After
a few days this material was firm and hard, and, after
imbedding it in celloidin, thin sections were readily cut."

The specific gravity is an aid to diagnosis. In cancenuis
it is low, liut in tuI)i'rculous effusions it varies between 1032-
1036 (Dock). Exceptions, however, can be found to this
statement for Bogchold ' and Quincke ° have reported cases
where the specific gravity of the cancerous eft'usion was over
1022. In the former instance the presence of a large amount
of blood might account for the high specific gravity. In our
case the specific gravity of the ascetic fluid varied between
1014-1020, while that of the pleural effusion was 1010 and
1017 (see Charts I. and II.).

The accompanying illustration shows the microscopical
appearance of the piece of tissue removed on April 10. The
photomicrograph was taken by means of the Zeiss apochro-
matic lenses. The microsco]u'cal findings were as follows:
Distinct alveoli are seen with lumina, more or less completely
filled with polymorphous cells, containing large, round or
oval, vesicular nuclei. The alveoli are gland\ilar in type and
their peripheries are lined by single layers of low cuboidal
cells. The stroma consists of a loose meshwork of connec-
tive tissue fibrillffi infiltrated with lymphocytes. No plasma
cells are seen. The diagnosis of adeno-carcinoma was made,
which was subsequently corroborated at autopsy.

I have only betn able to find four similar cases on record.

(1) Eieder' speaks of obtaining a small piece of tissue
from the puncture opening in the abdominal wall. The
case was diagnosed sarcoma carcinomatosum.

(2) Lenhartz found in an ascitic fluid a pale transparent
colloid nodule which showed the alveolar structure of a
colloid carcinoma of the peritoneum.

(3) Prentiss has published a ease in which the right pleural
cavity was aspirated, but no fluid was found. " Instead only

THE JOHNS HOPKINS HOSPITAL BULLETIN, OCTOBER, 1901.

PLATE XXXVI.

X .570. Objective G mm. Compeusat. proj. Ocular No. 0. Stain liaematoxylin-eosin.

OcTOBEIi, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

315

blood and a quantity of substance looking like partially
organized iibrin was drawn out, evidently from the lung
substance." This material was found on microscopic exami-
nation to be composed of masses of sarcoma cells. The
autopsy confirmed tlie diagnosis.

(4) Girvin and Steele have recently reported a case of
"carcinoma of the pleura, diagnosed by tissue removed in
tapping."

In conclusion, I desire to thank Dr. Osier for allowing me
to report this case, and Dr. Arthur J. Wolfe, of Hartford, for
the photomicrograph whicli accompanies this article.

Keferences.

1. Dock: Am. J. Med. Sc, Phila., 1897, cxiii, pp. 655-668.

2. Rieder: Deutsches Archiv f. klin. Med., Leipz., 1895,
liv, pp. 5-14-554.

3. Warthin: Med. News, New York, 1897, Ixxi, pp. 489-

491.

4. Bahrenberg: Cleveland Med. Gaz., 1895-6, xi, pp. 374-
278.

5. Bogehold: Berl. klin. Wchnschr., 1878, xv, pp. 347-349.

6. Quincke: Deutsches Archiv f. klin. Med., Leipz., 1875,
.xvi, pp. 121-139.

7. Rieder: Op. cit.

8. Lenliartz: Mikroskopie uud Chcmie am Krankenbett,
Berlin, 1895, p. 321.

9. Prentiss: Trans, of the Assoc, of Am. Pliys., 1893, viii,
pp. 191-194.

10. Girvin and Steele: Proc. Path. Soc, Phila., 1901,
New Series iv, pp. 164-166.

A CASE OF PRIMARY ADENO-CARCINOMA OF THE FALLOPIAN TUBE.

By Elizabeth Hurdon, M. D.

Clinical Assistant in Gynecology, The Johns Hopkins Hospital Dispensary.

New growths of the Fallopian tube were seldom mentioned
by the older writers, and by some, primary tumors were
believed not to exist. The descriptions of the early eases
are so meagre that in most instances there is not sufficient
evidence that the growth was not due to a metastasis from a
tumor arising elsewhere. The first imdoubted case of prim-
ary cancer was described by Ortlimann ' in 1888, and since
then thirty-four additional cases have been recorded.

The tumor in most instances originates in the epithelium
covering the folds of the mucosa and has, therefore, a well
marked papillary structure. Friedenheim," however, has
described a case in which the tubal folds are practically
normal, while the muscular coats are infiltrated with carci-
nomatous masses. This growth, as the writer suggests, prob-
ably originated in the gland-like structures, sometimes found
in the tube walls.

Most observers are of the opinion that a close relationship
exists between the development of the carcinoma and the
presence of a chronic inflammatory process. It seems prob-
able that this is an important predisposing factor, in many
cases the characteristic clianges resulting from an old inflam-
mation were demonstrable and in some the opposite tube was
converted into a sac containing serous or purulent fluid. The
history of sterility so generally obtained and often definite
attacks of pelvic inflammation tend to support this view.

Alban Doran ' believes that carcinoma is sometimes duo
to malignant changes in a simple papilloma, which itself may
be traced to inflammatory disease. The case reported by

'Orthmann: Zeitschrift fiir Geburtsh. n. Gyn. Bd. xv, 1888.
■^Friedenheim: Berliner lilin. Woch., No. 25, 1899.
^Doran: A System of Medicine, Albutt & Playfair. Trans, of the
London Obstet. Soc, vol. xl, 1898.

Kaltenbach * and the first case of Fabricius ' possibly belong
to this group.

Only a brief history of the present case could be obtained,
and is as follows:

Case No. 576, aged 63. Admitted to Dr. Kelly's private
sanatorium March, 1898. Complaint, sanious vaginal dis-
charge, elevation of temperature.

The patient had had four normal labors and had enjoyed
jierfect health until the summer before admission, when .she
sufi'ered from an attack of typhoid fever, after which she
noticed an almost constant blood-tinged vaginal discharge,
and was subject to frequent rises of temperature. Examina-
tion under an anesthetic revealed an irregular mass about tlie
size of a mandarin on the left side of the uterus. The tumor
was of rather soft consistency and was adherent. The right
tube and ovary were apparently normal. The uterus was
small and on curetting no tissue was removed. Pyosalpinx
was diagnosticated and operation advised.

Operation. — Abdominal hysterectomy, right salpingectomy,
left salpingo-oophorectomy. The right ovary, which was
small and perfectly normal, was left in situ. The uterus,
right tube and left tubo-ovarian mass were removed without
difficulty, but in separating some widespread adhesions which
surrounded the mass on the left side, the sigmoid was at one
point torn through to the mucosa. This rent was repaired
with a mattress suture of catgut.

The patient made an uneventful recovery.

Gyn. Path. No. 2376. The specimen consists of the
uterus, the right tube and a left tubo-ovarian mass. The
uterus is small and free from adhesions. Its mucosa is from

" Kaltenbach : Centralblatt, f. Gyn., 1889, p. 74.
'Fabricius: Wiener klin. Woch., 1899, No. 49.

316

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

one to two millimetres thick, and apart from a slight super-
ficial injection, appears normal. The right tube presents a
few light adhesions, but is otherwise normal.

The uterine end of the left tube for a distance of three
centimetres is moderately dilated and cystic, averaging about
one centimetre in thickness. It then suddenly expands into
a large cylindrical mass eleven centimetres long, three and
one-half centimetres in diameter. This mass is of a pinkish
or grayish color, covered with adhesions and somewhat
yielding to the touch. The fimbriated end of the tube is
firmly bound down to the ovary. The ovary is .5 x 4 x 3.5
centimetres in size and contains cysts from one to two
centimetres in diameter. It is also enveloped in adhesions.
The broad ligament is thickened and infiltrated. On cutting
open the tube in its long axis a greatly distended canal is
found, which is filled with a granular friable mass. This is
not attached on all sides, but springs chiefly from the outer
third and under surface of the tube, and the remainder of
the tube wall forms a thin smooth capsule around the mass.
On closer examination of the tumor it is found to consist of
finely branched papillary outgi-owths which, to a great extent,
have coalesced, forming a more or less homogeneous mass.

The fimbriated end of the tube has been replaced by the
neoplasm, and from it a papillary excrescence projects into
a small cyst cavity in the ovary.

Histological examination. — The uterus and right tube are
normal.

Sections from the margins of the tumor occupying the left
tube show in the earliest portions some swelling of the epi-
thelial cells and a tendency to become heaped up into little
folds. Further on we see branching papillary outgrowths
having a stroma composed of vascular connective tissue and
covered with several layers of epithelium. In the midtipli-
cation of the epitheliimi, small gland-like spaces have here
and there been enclosed. In most places the epithelial pro-
liferation has been so great that the papillary outgrowths;
have become fused and the sections present masses of epithe-
lium containing round and oval gland-like spaces, while scat-
tered here and there throughout the field are longitudinal
and transverse sections of stems of stroma (Fig. 3).

The epithelial cells on the whole are fairly uniform in size.
The deepest layer is composed of low columnar cells, while
the superimposed cells are polymorjihous, becoming flatter
on the surface. The gland-like inclusions are lined with
cuboidal or flattened cells. The nuclei are large, oval or
round, and have taken a somewhat deep diffuse stain. Mitotic
figures are numerous and show various irregular forms. In
favorable sections the papillary masses are seen to spring
directly from the inner surface of the tube wall, correspond-
ing to the folds of the mucosa: and at one or two points
normal folds may be traced for a short distance, then merge
into the tumor. In places the growth extends a short dis-
tance into the muscular coat in the form of solid nests of
epithelium, or as small glands lined with one or more layers
of cells (Fig. 3).

The portion of the tube invaded by the growth in places

shows considerable leucocytic infiltration, and the advancing
margin of the tumor is generally bounded by a zone of
round cells. The remainder of the tube is practically free
from infiltration and presents no evidence of an old inflam-
mation. The growth has invaded the ovarian stroma imme-
diately adjacent, and the cyst-like spaces with which the tube
communicates are lined in part with two or three layers of
tumor cells. The other small cysts are merely dilated
follicles and the stroma is normal. This tumor resemliles
in its finer structure the carcinoniata of the uterine body,
although its papillary formation is somewhat more distinctive
than in most tumors of the uterus. This may be attributed
to the fact that in the tulje the outgrowths spring from the
branched folds of the mucosa. On the other band, inasmuch
as glands are not normally found in the tubal mucosa and
the glands invading the stroma are therefore entirely due
to dipping down of the surface epithelium, the invasion is
apt to be less general than in carcinoma of the uterus.

That this tumor is primarily tubal is evident in view of the
following facts: ,

(1) The uterus is normal.

(2) The tube is large as compared with the ovary: ovarian
carcinomata grow rapidly and attain considerable size before
extension occurs.

(3) There is a definite relation between the papillary
masses and the tubal folds, while the ovary merely shows
invasion of parts adjacent to the tube and contains no papil-
lary excrescences, excepting those projecting from the end
of the tube.

(4) The mucosa of the tube is the site of the neoplasm,
the invasion of the musculature being due to extension
outward from the mucosa. In carcinoma of the tube, second-
ary to the ovary, the growth usually extends from the peri-
toneal coat inward and the canal may be normal or constricted,
not dilated.

For more than a year after the operation the patient en-
joyed excellent health. Then, however, she began to suffer
from a feeling of discomfort in the lower abdomen, and as
this persisted, an exploratory section was made in April, 1900,
about two years after the first operation. A small oval mass
about the size of an olive was found at the base of the left
broad ligament, and a nodule the size of a small bean on the
posterior surface of the bladder. These were dissected out,
but several minute deposits infiltrating the pelvic peritoneum
could not be removed. On histological examination the no-
dules removed proved to have the same structure as the
primary growth. At the present time, a year after the
second operation, the patient appears to be in good health.

Symptomatohfiy. — The earliest manifestation of the pres-
ence of the disease is usually, a watery vaginal discharge,
later becoming sanious. Hemorrhage is a variable sign:
in five cases there was metrorrhagia, and in two others
the menstrual flow was increased. Pain was present in
the majority of cases, sometimes occurring before the appear-
ance of the vaginal discharge, but more often later, and

THE JOHNS HOPKINS HOSPITAL BULLETIN, OCTOBER, 1901.

PLATE XXXVII.

a— -'-

t^".

"H,^~^,'%J3ft..

Oi''^S-'.

\Y'\

Fiii. I. — I'liiMAKV Carcinoma of the Tube. (Nutunil
size.) — a is tbe proximal end of tlie tube and 6 the
occhuled timbriated extremity. Near the uterus the
tube is uearly uormal in size, but rapidlj' enlarges until
near the timbriated extremity, it is .3 centimetres iu
diameter. At c are two subperitoneal cysts. The ovary
c, contains a small cyst with dark colored walls. At-
tached to the under surface of the ovary are several
adhesions.

Fiu. 3. Tkansvehse Section Tuuoui.n Uppeu Half of the Carcino-
MATODS Tube. (6 diameters.) — The tube is fully live times its normal
size. The wall, as represented by *(, apart from being somewhat thinned
out, is unaltered, h indicates the inner lining composed of one layer of
cylindrical epithelium, in places soniew'hat tlattened. The remnants of
the bases of the folds are indicated by c. The lumen of the tube as
indicated by the dark shade is completely tilled with epithelial cells of
the new growth. In many places these form a homogeneous mass, but
at the points Indicated by d assume a glandular arrangement.

Fig. :i. — Adeno Carcinoma op the Fallopian Tube. (.80 diameters.) The section is taken from the wall of the tube, a is the somewhat
llattened but normal tuba! epithelium. h a cross section of a normal fold and c the normal lining of a portion of a diverticulum from the lumen.
Penetrating the wall of the tube and occupying nearly half of the held is carcinoinatou.s tissue. The cells on the whole have fairly uniform nuclei,
but here and there they are deeply stained and increased in size. At several points, especially in areas indicatedby f/, a distinct gland-like arrange-
ment is demonstrable. Along the advancing margin of the growth there is considerable round cell intiltration, especially evident at e.

OCTOBBH, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

317

in some instances was only noticed a few weeks before the
time of operation.

In the two cases reported by Roberts " the patients experi-
enced severe attacks of pain, followed by a profuse serous
discharge with subsidence of the pain. These attacks oc-
curred at intervals of about three months until operation
was undertaken about a year after the iirst. Routier's ' pa-
tient gave a history of a similar attack. The presence of
ascitic fluid was observed in only a few instances.

Affe. — With four exceptions the disease appeared in the
fifth or sixth decade. The youngest patient was thirty-five
years of age, the oldest seventy years.

N.iiinber of pregnancies. — As will be seen in the following
table, absolute or relative sterility was noticed in almost all
cases. Data regarding the number of pregnancies were
obtained in twenty-four cases. Two other patients were
unmarried.

9 patients had no children.

3 " " " " but one miscarriage each.

7 " "1 child each.

2 " " '3 children each.

3 " "3 "

Diagnosis. — Carcinoma of the tube has not been diagnos-
ticated previous to operation, a diagnosis of ovarian cyst or
of hydro- or pyosalpinx, having usually been made. The
sudden onset of a serous or hemorrhagic vaginal discharge
at or about the time of the menopause, and following a long
period of sterility, at once suggests a new growth, as inflam-
matory disease usually becomes manifest in earlier life. If a
pelvic examination reveals a mass in one or both fornices,
and if the uterus is free from disease, there is probably a
new growth of the ovary or tube.

Ovarian tumors are less often accompanied by a vaginal
discharge and usually attain a greater size before giving rise
to symptoms. The differential diagnosis however is some-
times impossible.

In determining whether we are dealing with an innocent
papilloma or with a malignant tumor, the histological struc-
ture is chiefly to be considered. The simple papillomata
jircscnt a branched stem of connective tissue, invested with a
single layer of epithelial cells of uniform appearance, and
not tending to invade the stroma. In the carcinomata the
epithelial cells axe polymorphous, are usually in several
layers, and exhibit a tendency to invade surrounding struct-

« Roberts: Trans. Obstet. Soc, xl, 1899.

' Routier: Ann. de gyn. et obstet., vol. xxxix, 1893, p. 39.

ures. The papillomata, however, are always to be regarded
with suspicion, as is shown in the cases of Kaltenbach and
Fabricius referred to above In these the histological pic-
ture was that of an innocent tumor, but in each there was a
recurrence.

The thin walls of the tube and its intimate relation to the
broad ligaments favor extension of the growth beyond the
limits of the tube. It is essential, therefore, when removing
the tube to make a wide dissection of the pelvic connective
tissue. It is advisable to remove the opposite tube also, as
in twenty-five percent of the cases reported both tubes were
affected, and in three or four others carcinoma developed
later in the tube, which, as it appeared normal at the time of
operation, had not been removed.

The prognosis, so far as can be determined from the small
number of cases, is less favorable than in carcinoma of the
body of the uterus. We find that three patients died as a
result of the operation. In fourteen cases recurrence was
noted in from two to eighteen months. Three were appar-
ently well fourteen months, nineteen months and seven years
later, respectively. The remaining cases were either lost
sight of or were reported too early to furnish data as to
ultimate results.

In the March number of the Bulletin (after the above
article had been sent to the publishers) a case of carcinoma
of the tube was described by Dr. Le Count. The author
emphasizes the importance of chronic inflammation as an
etiological factor, comparing carcinoma of the tube to similar
lesions following hyperplastic inflammation in other organs.
I must, however, take exception to the writer's criticism of
many of the cases previously reported. Most of these cases
are carefully described in the original, and both the descrip-
tions and illustrations clearly indicate the presence of car-
cinoma. For example, in the case reported by Fearne from
Leopold's laboratory, Le Count apparently considers the
growth to be a simple polypous hyperplasia. I have, however,
had the opportunity of examining sections under the micro-
scope and agree with Dr. Fearne's diagnosis.

In regard to the adeno-carcinoma of the uterus described
by Cullen in his recent book, which Le Count declares is
merely a case of polypous hyperplasia, it is evident that the
latter writer has not studied the case carefully, as from the
description it is seen that many portions of the growth show
the typical picture of adeno-carcinoma. I have personally
studied the case carefully and there is not a doubt as to its
being a glandular carcinoma.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice, abstracts of papers read, and other proceedings
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Volume XII is in progress. The subscription price is $1.00 per year. The set of twelve volumes will be sold for $23.00.

318

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

LIPO-MYOMA OF THE UTERUS;

By J. 11. M.YsoN Knox, .Jk., Ph. D., M. D.
Clinical Assislant in Gyneculogy, The Johns Ilupkins llospital Dispensary.

Althougli fatty tumors are frequently found in many parts
of the body, the presence in the uterus of a new growth, con-
sisting in large part of adipose tissue is so rare as to lend some
interest to the report of the following case:

The patient was a woman, aged 62, married, and the
mother of thirteen children, the youngest 24 years of age.
The laliors had all been natural. She had had three miscar-
riages, the last twenty-six years before. Her nienstnral his-
tory had been perfectly regular and normal. The menopause
occurred twelve years previously. The family and personal
history was excellent. She had always been in good health.
The first indication of any abnormality occurred nine years
ago, when the patient noticed a slight serous vaginal dis-
charge. This passed away after some weeks and did not affect
her general health. The discharge returned after an interval
of over eight years, but again hosted but a short time, and
was accompanied by no untoward symptoms. For two weeks
before examination she had been bleeding moderately, but
continuously. The discharge has never been offensive. On
only one occasion did the patient suffer when she complained
of a sharp pain like that during labor. Her appetite was
good and the bowels were regular. There was slight in-
creased frequency of micturition. The patient thought that
she had gradually lost in weight. The heart and lungs were
normal.

On abdominal and vaginal examination a large firm tumor
was found connected with the uterus, filling the pelvis and
extending almost to the umbilicus. Operation was advised
and performed by Dr. H. A. Kelly and a large mass, includ-
ing the uterus and appendages, was removed by the supra-
vaginal route. The tumor was not densely adherent, and the
oj)eration presented no unusual difTiculties, except for rather
free haemorrhage, which was finally perfectly controlled.
The patient made a slow but satisfactory recovery and is at
present, eighteen months after the operation, in fair health.

During the operation and indeed for some time afterward
there was no suspicion that the mass did not consist of a
simple large myomatous uterus. It was only in the routine
examination of the specimen in the laboratory that its un-
usual structure was discovered. Hence it is to the patho-
logical description that most interest attaches.

Pathological description (Gyn. Path. No. 3703). — The speci-
men consists of a uterus involved in a large tumor, both
Fallopian tubes, a portion of the left ovary, and a cystic
right ovary. The uterine mass is globular in form, regular
in outline and approximately 15 cm. in length, 14 cm. in
breadth and 18 cm. in its antero-posterior diameter. The
surfaces are generally smoothly covered by peritoneum. On
the left side, however, above the attachment of the tube, the
surface is roughened by numerous tags of adhesions. The

tumor is hrm and resilient in consistency. The uterine
cavity is about 14 cm. in lengih. The mucosa of the anterior
wall is glistening and is hardly 1 mm. in thickness. It is
everywhere intact. That covering the posterior wall is much
altered on account of the tumor which projects into it from
behind. In some places many minute cysts are scattered
throughout the mucous membrane, some of them being 2 mm.
in diameter. In the uper part of the cavity is an area 4x4
cm., irregular in outline, sharply defined and very pale in
color. At this point the mucosa is excessively thin and the
tumor in the posterior wall almost comes in direct contact
with the uterine cavity. In the lower part of the cavity is
another pale area 9x9 em. Here the mucosa is also thinned
out but at numerous points it is still preserved, as witnessed
by the snuiU cyst-like spaces — dilated uterine glands. Sit-
uated in the upper part of the cavity is a sessile polypoid
thickening .5 x 2^ cm. Here the mucosa varies from 1-7 mm.
in thickness; some of the glands here are 1.5 mm. in diameter.
The anterior uterine wall varies from .8 to 1 em. in thickness
and presents no abnormality. Occupying the posterior wall
is a tumor mass somewhat globular in form (Fig. 1). It
is apjjroximately 10 x 13 x 10 cm. in size. On section the
tumor to casual examination presents the appearance of
myoma, but on more careful scrutiny is found to be markedly

difl'e

Traversing it in all directions are glistening bands

*Read before the Johns Hopkins Hospit.al Medical Society, March 18,
1901.

between which are yellow soft looking areas. On scraping
the cut surface distinct oil globules can be brought away, a
thing that is never possible when an ordinary myoma is exam-
ined. The tumor itself presents no areas of breaking down.
It is sharply defined from the surrounding uterine muscle,
which varies from 3-5 mm. in thickness. At the point where
the mucosa is pale-staining the tumor encroaches upon
the uterine cavity to a marked extent aiul the mucosa here
shows much atrophy.

Appendages. — On the right side the Fallopian tube is aji-
proximately 12 cm. in length, normal in consistency, and
presents a uniform diameter of about 4 mm. Its surface is
everywhere roughened and the fimbriated extremity is densely
adherent to and occluded by the large ovary about to be
described.

The ovary is converted into a lobulated nuiss, partly cystic,
])artly firm. The mass is somewhat bean shaped in outline
and measures 8x5x4 cm. The inner pole is quite hard in
consistency and on section is seen to be made up of dense
librous tissue.

The harder portion merges into a small multilocular cyst
which has a smooth, glistening surface with thin walls, and
contains an iridescent yellowish fluid.

The cystic portion is divided into looulfe of various shapes
and sizes by firm trabeeulae.

The several small pedunculated masses project into the
cavity of the cyst.

October, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

319

The left side: Tube presents practically the same appear-
ances as the right side. No induration; the surface is every-
where roughened, but a vestige of ovarian tissue remains in
tlie broad ligament.

Microscopical dencription. — On microscopical examination
the round tumor mass is found to be made up of large fat
cells enclosed in a supporting substance composed of smooth
muscle and connective tissue in varying proportions. The
fat cells are generally round or oval, occa.sionally ])oly.ironal
or irregular in outline from pressure upon eacli otlier. They
vary in size from 5 to 15 times the diameter of a red blood
corpuscle and a])pear, after hardening by the usual processes
in whieli the fat is dissolved, like clear spaces (Fig. 2).
The nuclei of these cells can frequently he made out as oval
or rod-shaped bodies pushed to the perijihery and often
situated in an angle between several of tlie cells. The tumor
is coursed throughout its extent by numerous bands of firm
filirous tissue whicli produce the lobulatcd a]ipearance noticed
in the gross specimen. This more solid material consists of
round and spindle cells of the connective tissue type, having
finely granular protoplasm and oval or spindle-shaped deeply-
staining nuclei, together with a considerable c[uantity of
intercellular substance. Intimately mingled with it in many
parts of the growth are the longer cells of the smooth muscle
type with rod-shaped, often wavy, nuclei. Considerable
areas made up of connective and muscle tissue and containing
no fat cells are met with throughout the tumor. The bulk
of the tumor, however, is composed of groups of fat cells
surrounded by irregailar coarse bands of this firmer tissue.
From larger bundles small filaments are given off which
encircle the individual cells. These finest filaments appar-
ently fuse with the cell walls so that numerous cell groups
are met with in whicli the large globular fat cells appear to
be in direct contact. In the larger bands of the supporting
tissue are many larger blood-vessels, and numerous capil-
laries are present in the smaller septa. Many cells contain-
ing coarsely granular protoplasm, staining in eosin and having
irregular deeply-staining nuclei (eosinophiles), are met with
throughout the specimen, more particularly about the blood-
vessels in the central portion of the tumor. Another form
common in the growth are large round oval cells with a some-
what refractive protoplasm and rather palely staining nuclei.
The cells of this variety, probably Mastzellen, are found
between the processes of the connective-tissue cells. No-
where in the specimen are fat droplets seen inside of either
muscle or connective-tissue cells; that is to say, there is no
evidence whatever of fatty degeneration. Occasionally more
or less extensive areas are met with which stain homoge-
neoiisly with eosin and are devoid of nuclei. These arc areas
of hyaline degeneration. The structure of the tumor is not
materially altered as one approaches the periphery. The
muscle tissue like that usually found in the uterine wall
forms the immediate boundary of the mass on all sides, thus
showing that the growth must have been interstitial in
origin. In general, it may be said that the tumor is rather
sharply demarcated from the surrounding tissue. In many

places, however, the muscle near the growth contains here
and there scattered fat celbs, and occasionally groups of them
in the muscle render the transition to the tumor proper a
more gradual one. The muscle cells themselves present no
abnormalities. Where the pressure of the growth is most
marked they are often arranged in rows parallel to the cir-
cumference of the tumor. Numerous blood and lymph ves-
sels are present throughout the uterine wall. Here, too,
there is no evidence of fatty degeneration. Beyond the
upper and lower limits of the tumor the muscle wall is much
thicker. This is jiarticularly true interiorly in the portion
corresponding to the cervix wliere it is over 1 cm. in diameter
and composed of irregularly arranged dense muscle bundles.
As one ascends, however, over the protruding anterior face
of the tumor the iiniscle bands become rapidly thin, frayed,
and often ditficult to distinguish from the connective tissue
of the mucosa. Areas of hyaline degeneration are not in-
frequent in the muscle wall, particularly near the tumor.
The uterine muco.sa jtresents a varied picture. For the most
part it is much n-duccd in thickness. The surface e])ithe-
lium over the tumor is preserved in protected areas, where
it consists of a single layer of low cylindrical ciliated cells.
The stroma is rather dense and made up of the usual round
and oval cells with darkly staining nuclei, and a considerable
amount of finely granular intercellular substance. The uter-
ine glands are exceedingly few in number throughout most
of the mucosa. When found they consist of snuill irregular
or simple tubules lined by cylindrical epithelium. They are
situated for the most part quite near the surface. The
mucosa which does not cover the projecting growth is also
thinned. Here, however, many small uterine glands are
present and the stroma is proportionally more cellular. The
polypoid thickness (sessile polyp) is made up of loose con-
nective tissue, consisting largely of round and oval cells.
Scattered all through this area are numerous glands varying
from simple tubules to cysts of considerable size. The for-
mer are lined by high cylindrical epithelium one cell in
thickness. The epithelium of the more dilated txdjules is
lower, while the cells lining the larger cysts are cuboidal in
type. Many dilated capillaries are present in this raised
area, which thus jiresents the usual structure of uterine polyp.

Appendages. — Eight side; tube. Sections taken at several
points along its course fail to present any abnormalities in the
structure of the tube. Near the cornu the epithelium lining
the lumen is slightly wavy in outline, while toward the
fimbriated extremity the mucosa is gathered into intricate
folds and convolutions. The stroma and muscle layers ap-
pear normal. The outer surface of the tube is markedly
roughened, as though torn away from adhesions.

Ovary. — The solid portion of the enlarged right ovary is
made up of a rather cellular connective tissue, the cells are
oval or fusiform, have deeply staining nuclei and are sepa-
rated from each other by a large amount of finely granular
protoplasm.

The walls of tlie multilocular cyst occupying the outer
pole of the ovary are composed of a thin framework of con-

320

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

nective tissue lined by epithelium usually one layer in thick-
ness, the cells varying in outline from a very low cuboidal to
a high cylindrical type, according to the amount of pressure.

The small pedunculated masses jirojecting from the cyst
wall into the lumen consist of a fibrous stalk covered by
epithelium similar to that lining the remainder of the cyst.
In several areas the epithelium appears to be more than one
layer in thickness.

Left side; tube. Sections of the tiU)e near the uterus and
toward the fimbriae present the same appearances as those
noticed in the right tube. The outer surface is likewise
roughened.

Ovary. — But a small bit of the left ovarian tissue was
found in the specimen. This is senile in type and made up
of stroma cells rather closely packed together. No Graaffiau
follicles are seen. There are in places through the section
coarse wavy bands of hyaline material, probably the remains
of ruptured follicles. A few corpora fibrosa are present.
At one jioint is a gland-like space nearly 1 mm. in diameter.
This is lined by cells almost flat and containing oval deeply
staining nuclei. At the opposite pole, possibly near the
liilum, is a large amount of unstriped muscle fibre.

Consideration of the above findings leads to the conclusion
that one is dealing with an actual new growth in the uterine
wall composed of adipose tissue, the cells of which indi-
vidually or, in groups are surrounded by a marked increase in
the smooth muscle and fibrous tissue elements in the pro-
portion frequently found in so-called myoma uteri. The
fact that no fat droplets are present in the cells of the firmer
tissues and the absence of areas of softening in the tumor
preclude the possibility that the condition may be due to a
fatty degeneration, and suggests the unusual diagnosis of
lipo-myoma of the vterus as being most properly descriptive
of the specimen. That the right ovary is the seat of a small
fibrous growth and a multilocular cyst, has of course no
association with uterine tumor.

An examination of the literature at hand shows that Init
few, if any, cases of an exactly similar nature have been
rejiorted. As is well known, various degenerations of myo-
matous uteri are not imcommon and may be of such marked
grade as to occupy a large part of the tumor.' Several cases
have ])een recorded, chiefly by older writers, of tumors of the
uterus which consisted of more or less homogeneous whitish
or yellowish material, described variously as " Pure white
fat," ■ " Hard white fat insoluble in alkalies at boiling heat," '
" Yellowish white glistening substance, containing crystals
of cholestrian." *

These tumors, called by the authors " steomata," " insteo-

'Bruunings: Verhandhingen der Deutsche Gesellseliaft fiir Gynae-
kologie, Bd. VIII, p. 348.

• Dressel, von Graefes und von WaltluTS, and .lournal fiir Chinirgie
und Augenlieilkunde, ISSS, Bd. XIX, p. 661.

^ Dr. "Wm. Bush. Edindurgh Medical and Surgical Journal, 18.53, Vol.
79, p. 381.

■• H. B. Allen: Australian Medical Journal, 1879; n. s., 1, p. 536.

mata " or " eholesteomata," respectively, are likewise in-
stances of degeneration and are not primary growths.

Meckel ' speaks of a tumor, involving the uterus described
by Lobstein.' The uterus was enlarged to the size of a seven
or eight months" pregnancy by a " fatty tumor."

In 1853 Seegar ' described a case which seems to resemble
the one here reported. It is briefly as follows: A widow,
aged 53, had for a year suffered from rather severe metro-
rrhagia, not relieved by any internal medication. On examin-
ation a round mass, the size of a child's head, bluish in
color and elastic in consistency, was found protruding from
the external genitalia and held by a pedicle surrounded by
muscle fibres. The pedicle was ligated and the mass re-
moved. The mass " consisted of a fatty tumor covered by a
firm cetlular membrane and coursed hy fibrous tissue Ijands.
Parts of the tissue were rather soft, others firm and poor in
blood-vessels." The patient made a good recovery. No
microscopic description is given.

In 18(51 T. Smith " presented to the Pathological Society
of London a specimen removed by Mr. Paget from a woman
aged 40. It consisted of a pedunculated mass the size of two
fists united to the fundus iiteri, but protruding between the
labia. On section the tumor was made up largely of firm
fibrous tissue but contained a small serous cyst and an
" adipose tumor, the size of a pigeon's egg, complctrly embedded
in the substance of the larger tumor and surrounded by a fibro-
cclhdar capsule, from which it ivas easily shelled out." No
microscopical description is given.

A case of somewhat different nature was reported in 1S80
by Sehoinski." On examining a woman, aged 28, who had
been married seven years, to find if possible the cause of her
sterility, he discovered on the anterior lip of the cervix a
small movable tumor which on pressure could be easily forced
into the os, closing it like a valve. This was excised and
" proved to microscopical examination to be lipoma." The
patient became pregnant three months afterward.

It is evident, therefore, that an adipose tumor of the uterus
is an exceedingly rare condition. A lipoma in this situation
is also of interest because, as there is no fatty tissue whatever
present normally in the uterus, a lipoma of this organ lends
support in a limited way to the theory of Cohnheim as to the
histogenesis of tumors, namely, that they arise from some
misplaced embryological element.

I take pleasure in expressing my thanks to Dr. Kelly for
the privilege of reporting the case, and to Dr. T. S. Cullcn
for much assistance in the interpretation of the specimen.

Discussion.

Dr. Cullen. — I think this is a most interesting find. We
have bepn making a sj-stematic examination of all cases of

* Handbuch der pathologische Anatomic, Vol. II, p. 311.
« Sur r organisation de la matrice, Paris, 1803, No. 1.5, p. 8.
'Zeitschr. f. Wundaerzte und Geburtshiilfe, 18.53, Vol. V, p. 24.
s Transactions of the Pathological Society of London, 1861, Vol. 13,
p. 148.

9 Chicago Medical Review, 1880, Vol. 1, p. 469.

THE JOHNS HOPKINS HOSPITAL BULLETIN, OCTOBER, 1901.

PLATE XXXVIM.

dW^

^inucoub pulyp

cavity

j[ BecKer.

ftrit-

The posterior wall
This is due to the

Fig. 1. — Lipo-myoma of the uterus, natural size. The uterus has been longitudinally bisected. The left half is shown,
is seen to be the seat of a large globular tumor, presenting on cross section the irregularly lobulated appearance described,
inclosure of fat cells by trabecuhe of firmer tissue. The tumor is rather sharply demarcated from the surrounding uterine wall, which is every-
where thinned, the portion between the growth and the cavity being particularly atfected. Near the superior limit of the cavity is a sessile uterine
polyp seen in cross section.

'"l;^

,-<^;

hH^.

g^iwf!..

Fifi. 3.— Lipo-myoma of the uterus (.50 diameters). The section consists of a network, " b," composed of uou-stripped muscle fibres and
connective tissue in varying proportions. The interspaces, "c," are fat cells. At some points they are very abundant, at others isolated, "a" are
blood vessels. Sections from all parts of the tumor present essentially the same appearances.

October, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

321

myomata and though over 600 specimens have been examined
we have found but the one case of this character.

In nearly every myoma there is a hyaline degeneration in
some part of the growth. This is usually diffuse, but in a
certain percentage of the cases a large circumscribed area
undergoes this degeneration. In the centre of such a block
of hyaline tissue there is a gi-adual melting away, and we
find nothing but a few threads of connective tissue and in the
spaces between these free fat looking very much like melted

butter. In this free fat cholesterin crystals are frequently
present.

A problem that is attracting a great deal of attention at
present is the degeneration that takes place in myomata.
It has been a mooted question for some time as to whether or
not myomata can become malignant. We have in the labora-
tory at present at least three specimens in which the centres
of myomata contained sarcomatous tissue.

CHOREA WITH EMBOLISM OF CENTRAL ARTERY OF RETINA.

A SHORT REVIEW OF THE EMBOLIC THEORY OF CHOREA.

By Henry Thomas, M. D.,
Clinical Professor of Nervous Diseases, The Johns Ilophins University.

The subject of this communication is a young girl in ap-
parently perfect health, except for slight choreic movements,
which involve the right arm and leg, and very slightly the
face. A closer examination shows, however, that she is suf-
fering from the effects of an extremely rare and interesting
complication of chorea, viz.: Embolism of the central artery
of the retina. An abstract of the history, taken in the
Neurological Dispensary of the Johns Hopkins Hospital, is
as follows:

Dis. Nerv. System, No. 11,722.— Elizabeth C, age 16;
sewing machine worker, was admitted to the dispensary Jan.
31, 1901, complaining of nervousness.

The family history is unimportant, except that one of her
three brothers has had rheumatism, and that her mother, at
the age of 51, is suffering from a facial tic of the left side.
Other than this there is no history of any nervous disease in
the family.

Personal History. — The patient is the fifth child of six;
her birth was normal. She was healthy as a child, and
developed normally. She had measles and whooping-cough,
but no other infectious diseases and has never suffered from
rheumatism. She began to menstruate at fourteen, and has
since been regular.

For the last three years the patient has been working in
a factory at a sewing-machine, which is run by power. She
has been industrious and ambitious and her mother thinks
that overwork may be accountable for her present trouble;
at least neither mother nor daughter can think of any other
possible cause.

Present Illness. — About six or seven weeks before she came
to the hospital, an unsteadiness in the movements of her
right hand attracted attention. This was noticed at table,
and while the patient was at work in the factory. There
was no change in her disposition, but a certain awkwardness
developed in her speech. The movements also involved the
legs on the right side.

The patient says that she has been unable to see with the

left eye since the trouble began; but unfortunately she can
give no definite account as to exactly when this blindness
occurred. She says that it came on suddenly, and when she
discovered the defect it was as complete as it is now. She
also thinks that she was first conscious of it at about the
time she began to be nervous. I have been unable to get a
more definite history from the other members of the family.

Examination. — At the time of the first visit, the patient
showed a mild grade of choreic movements which were lim-
ited to the right arm and leg, with occasional movements of
the face. Speech was not noticeably affected. She was
slightly anemic — hemoglobin being about 70,^. Examination
of the heart by Dr. Jacobs revealed a slightly dilated heart,
with a rough blowing systolic murmur, heard at the apex.

Vision in the right eye was normal, but that in the left
eye was absolutely nil. The right visual field was normal
both to form and to colors. The ophthalmoscopic exami-
nation showed optic atrophy of the left optic nerve with
markedly contracted arteries. The right optic nerve was
normal. The pupils were equal, and were between .5 and
5J mm. in diameter. In a dim light, however, the left pupil
was slightly larger than the right. The right pupil reacted
actively when light was thrown into that eye, but not at all
when light was thrown into the left eye. The left pupil
contracted when light was thrown into the right eye, but was
immobile when the light was thrown into the left eye; that
is, the right pupil reacted to direct light, but not consen-
sually, whereas the left pupil reacted consensually hut not
directly. When the patient endeavored to fix an object
brought close to the face, both eyes converged and lioth
liupils contracted. When the right eye was closed the pa-
tient was unable to make the effort to accommodate with her
left eye.

When first examined, it appeared that the left pupil
dilated and contracted synchronously with the choreic jerks;
upon the second visit, however, the right eye being bandaged
and the left pupil being carefully watched, this observation

322

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

could not be confirmed. Nor was it possible to discover any
choreic movements of the external muscles of the eye,
although the ball showed the unsteadiness so often seen in
blind eyes.

Tlie case i)rescnted the tyi)ical jiictnre of unilateral chorea
of slight grade, witli involvement of the optic nerve, and the
probable diagnosis of embolism in the centi'al artery was
made, although at the time I did not recall having heard of
any similar case. The patient was referred to Dr. Eeik for
ophthalmoscopic examination, and he has kindly made a
careful examination, and will describe the condition which he
found. He confirmed the diagnosis of embolism of the cen-
tral artery of the retina.

The eye complications of chorea are not very numerous.
Muscles of the eye-ball are at times, though rarely, the seat
of choreic movements. Growers ' calls attention to the fact
that the movements may be unequal in the two eyes, and
so cause diplopia. This l)eing transient, is not often com-
plained of. The pu])ils have been described as dilated, and
as reacting sluggishly or not at all to light. This state-
ment which is an old one, has not been confirmed by later
observers, who state that the pupils are usually normal in
their size and action. Choreic movements of the iris, such
as I at first thought were present in the case described
above, have been described by Dr. 11. B. Scheffield,' who
observed in a choreic girl of 10 the most remarkable move-
ments of the pupils. They would dilate as well as contract
repeatedly within one minute. At times they were the size
of a jiinhead and at times they W'ore dilated ad inaximiim. He
confirmed the occurrence of tliese movements repeatedly dur-
ing the attack of chorea. They disappeared when the patient
recovered.

Gowers ' refers to optic neuritis as not very uncommon.
Usually slight. He says, however, that twice * he has seen
it of such a high grade of intensity as to suggest the presence
of a brain tumor. It subsides with the chorea.

Atrophy of the optic nerve is said to have been observed,
and Schmidt-Rimpler ° refere very briefly to such a case.
These are probably cases following embolism of the retinal
artery or are associated with some disease other than chorea.

Embolism of the central retinal artery is the complication
whieh interests us particularly at this time. When referred
to at all by the authors it is always spoken of as being ex-
tremely rare. Gowers, in his Medical Ophthalmology, says
that there have been only two cases (Swaiizy and Fnrster),
and in his text-book he refers to only one — l)ut tliis, a third
case, that of Sym. Knies ° speaks of the cases of Swanzy

'Trans. Opbtb. Soc. United Kinffdom, 1884, iv, 300.

2 Am. Med. and Surg. Bull. New York, ISOfi, vol. x, p. 373. "A case
of Chorea Minor, involving also the ciliary muscles."

»Med. Ophthalmoscopy. Third edition, ISOO, p. 198.

^ In the second edition of his Diseases of the Nervous System, 1893,
vol. ii, p. 604, he states that he has seen but one such case.

5 Nothnagel Special Path., etc., 1898, vol. xxi, p. 46.

'Relations of diseases of the eye to general diseases. New York,
1895, p. 340.

and Sym. Schmidt-Rumpler ' has also no new cases to cite,
and simply mentions these cases referred to by Gowers.

Swanzy," besides his own case, gives references to the cases
of Benson and Leber.

I have been unable to add very materially to this list in
my somewhat hurried view of the literature. It was ijointed
out long ago by Trousseau, in his Clinical Lectures,' tliat
imjiairment of sight had been ol)served by several authors,
and lie, himself, records a case. This impairment of sight,
which he says, is probably due to paralysis of the retina is
an accident excessively rare. The first well-reported case,
as far as I have been able to find, was that of Swanzy, which
is so generally refeired to. On account of the great interest
of these cases I shall give a short abstract of this case and
of the others which I have collected.

Dk. Swan:iy's Case.'" — Lizzie, , age 10. Seen IG

days aft(>r onset. Patient noticed upon waking in the morn-
ing following a long day of sight-seeing that she could not
see witli the left eye. Choreic movements, more marked
on the left side, made their ajijiearance at about the same
time. The o])hlhalmoscope revealed the typical picture of
a recent embulism of the central artery. No heart lesion was
found. Ojitic atrophy followed. The chorea disappeared.

Dr. Leber's Case. — I. H. Leber" says: "I have seen a
single example of one-sided atrophy of the optic nerve in
connection with chorea which was apjiarently due to embol-
ism of the central artery. The patient was a girl eight
years old. who had suffered from chorea for a number of
years. The loss of sight had followed very suddenly a few
mouths previous to the examination. Well-marked, one-
sided atnipliy of the nerve was found, the vessels being of
very small caliber. Amblyopia Amaurotica existed. The
second aortic sound was of an increased intensity, which only
strengt-hcned the theory of an emiiolic jirocess being the cau-
sative factor in the optic atrophy.

Dr. I'enson's Case." — James Jackson, age 21. Eheu-
matic fever when 17; chorea at 18; recurrence when 19 and
again when 20. AVhen 21, the day before admission, he
became ])rogressively but quickly blind in the right eye; he
could not see light. In about ten minutes the sight im-
proved in the lower field. When examined, there was com-
])lete loss of the upper half of the right visual field. The
ophthalmoscoj)e showed the characteristic picture of embolism
in the inferior division of the central artery. No lesion of
the heart could be discovered. In 2 months the oidithalmo-
scopie picture was normal.

Dr. Ball's Case." — Boy, age 1."). Maternal grandmother

'Loc. cit., p. 286.

8 System of Diseases of the Eye. Norris and Oliver. 1900, vol. iv,
p. 630.

'Bazire's Trans., p. 403.

i» H. R. Swanzy, Ophthalmic Hospital Reports, vol. viii, p. 181.

"Graefe und Saemisch. TTaudbuch dor .\ugenheilkunde, 1877, vol. v,
p. 870.

''■The Ophthalmoscopic Review, 18S6, vol. v, p. 1.

i:i Transactions of Clinical Society of London, 1887-8, vol. xxi, p. 379.

October, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

323

and two brothers had rheumatism. Patient had not suffered
from rheumatism. 1st attack of chorea 8 years before, since
which he has never been quite free; worse for the six mouths
before examination. Five days before he was seen, he noticed
in the morning a darkness before tlie riglit eye; lie could only
see the upper part of objects with that eye. Tiie fundus was
normal with the exception of an arterial branch which was
constricted, especially at its origin. There was haziness of
the retina in the distribution and of the adjacent section of
the optic disk. The apex of the heart was in its normal
position, and there was a soft systolic apex bruit.

Dr. Stm's Case." — G. S., boy, age 17. Plad been well up
to his seventh year, when he had chorea, which was not very
severe. Was in the Infirmary and doing well; when walking
one morning in the ward he felt a sudden mist come over
the right eye. He has never seen out of it since. Examina-
tion showed left eye normal — right eye absolutely blind. In
endeavoring to fix a near object, the right eye did not con-
verge.

Right eye did not contract to light, but did so in sym-
pathy to left. The right optic nerve was atrophied. There
was a presystolic murmur and a reduplication of the second
sound. In speaking of the rarity of these cases, Sym said
that " Dr. Argyll Robertson informs me that a few years
ago he saw a precisely similar ease — that of a young lady in
whom atrophy of one optic nerve succeeded a severe attack
of chorea."

Forster's Case. — " The other case was recorded by For-
ster, but was not seen until some time after its occurrence.
The patient, a child, had suffered from chorea for some years
and during the chorea, had lost the sight of one eye. The
disc was atrophied and the arteries very small."

Besides these cases, I have no doubt others could be found
in which the embolism occurred at a late period in eases of
chorea, followed l)y heart lesions. For instance, one of the
cases pictured by Frost in his beautiful Atlas, " The Fundus
Oculi,'° is that of a woman, 50 years old, who had had rheu-
matism when nine years old and several attacks of chorea
between 11 and 15, rheumatic fever at 38 and again at 49,
and embolism of the central artery at 50. But such cases
can hardly be considered as complications of chorea.

Ophthalmologists are not in accord on the subject of embol-
ism of the central artery, and a number of excellent observers
believe that many of the cases classed imder this head are
examples of thrombosis. Their objection is that no source
for the emboli can be found, while the causes which favor
thrombosis are present. These objections can not be urged
against the cases occurring in chorea, especially when there
is a demonstrable lesion of the valves of the heart.

Not only do the authors who describe such cases consider
them dependent upon emboli, but with hardly an exce])tion
they all point out the support which they lend to the theory

it.

"Edinburgh Med. Jour., 1888, March, p. 811.

'=Gower3 Med. Ophthalmoscopy, p. 108. — I have been unable to trace

"London, 189(1, [il. xli.

of the embolic origin of chorea. Swanzy," writing very
lately, in reference to this point, says: " Possibly therefore
the embolic theory of chorea may yet be found to be more
tenable," at least for some cases of that affection, than Gowor
believes and Knics" is still more positive with the statcMuent:
"These two cases (Swanzy and Sym) demonstrate the de-
velopment of chorea by multiple emboli; however this is not
the sole cause of the disease."

The embolic theory of chorea is of great historical interest,
and as it is so little referred to in modern text-books, a brief
review may be of value.

The association of chorea with rheumatism and lesions of
the heart was noticed in the 18th century, but particular
attention was first drawn to it about the middle of the last
century. Roger, in France, 186G, went so far as to state that
rheumatism, chorea and endocarditis were all manifestations
of the same poison. In England, where a great deal of
attention had been paid to chorea and to this association, the
relation between these conditions had received another ex-
planation. Kirkes'° advanced the theory that the relation
was not between chorea and rheumatism but lietween chorea
and valvular heart disease excited by rheumatism. He con-
sidered that chorea usually follows the heart disease, and he
said: "And I now believe that whenever chorea occurs in
association with acute rheumatism, the valves of the left side
of the heart are inflamed and therefore the association is not
between chorea and rheumatism but between chorea and val-
vular heart disease excited by rheumatism. ... We can
readily understand that the blood in such cases often pre-
viously unhealthy from rheumatic poison and now rendered
still more impure by the introduction of inflammatory pro-
ducts and fibrinous particles from the diseased valves, is
calculated to disturb very materially the functions of the
various organs through which it circulates." Later he says:
" Partly by the mere circulation of morbid blood through the
nervous centers, partly also perhaps by temporary obstruction
in the minute capillaries, occasioned by fibrinous particles
arrested therein, the irritation leading to the development of
chorea or other analogous phenomena may be accounted for."

About this time great interest was aroused in the physi-
ology of the bi'ain. Broca had demonstrated that speech
was located in a definite part of the brain cortex. Hugh-
lings Jackson had deduced from his clinical observations that
there must be some sort of localization of the movements in
the brain. The cortex had, as yet, not been proved to be
excital;)le liy electric stimuli, so it was thought that this lo-
calization of moti(.n was to be looked for in the so-called sen-
sory-motor ganglia, and particularly in or al)out the corpora
striata. The tact that chorea so often afl"ected the muscles
of one side of the body, and that when it was bilaterial. it was
usually unequal, pointed to the brain as being the seat of the

" Norris and Oliver's System, 1000, vol. iv.

'«Loc. cit.

"Med. Times and Gazette, ISfiS, vol. i, pp. 6:^6-663.

324

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

lesion, and Hughliugs Jackson,"" Broadbent,°' Knsscll Rey-
nolds, and others assumed that it was in or about the
corpora striata that the primary seat of the disease was to
be sought, and adopting Kirkes' view, they taught that multi-
ple emboli wore the most probable cause. This theory, sup-
ported by such men, carried great weight, but it was never
generally accepted. For it was pointed out that in the cases
of chorea which came to autopsy emboli could only rarely be
demonstrated, and in eases where emboli were found after
death, chorea had very seldom been j^rescnt. Dickenson"
gives most interesting data on this subject after detailing the
anatomical findings is seven cases of chorea.

The embolic theory appeared, however, to receive a
certain experimental confirmation from the work done by
Money,^^ who succeeded in producing in the lower animals
movements which could not be distinguished from those of
chorea. He did this by introducing into the circulation minute
particles that could be easily recognized by microscopical ex-
amination. He found that the choreic movements resulted
only when the emboli lodged in the capillaries of the upper
part of the cord. AVhen the brain was the seat of the emboli,
many other " forced movements," but not those of chorea.
These experiments, he believed, demonstrated that choreic
movements could be produced by capillary emboli, but he
did not argue from them that human chorea depended upon
a disease of the spinal cord. Against this there were too
many well-known facts which spoke definitely for the brain
being the seat of the process. He spoke of continuing these
experiments upon monkeys, but of these I have seen no
report. In the interesting discussion of Money's paper,"*
Hughlings Jackson, Broadbent and others took part. Hugh-
lings Jackson and Broadbent referred to their former views
and seemed to think that these experiments were to a certain
extent confirmatory of them. Dickenson"" again reviewed
the subject in the light of Money's experiments, but was
unable to find any confirmation for the embolic theory of
chorea from the pathological reports of St. Georges Hospital
and the Hospital for Sick Children.

This and similar investigations, as well as certain well-
known clinical characteristics of chorea, spoke so strongly
against the theory, that it was practically abandoned. Gowers
speaks of it as of merely historical interest.

It is not my intention to speak in detail of the current
theories that have been advanced in the endeavor to explain
the etiology and symptoms of chorea. They will be found
very fully discussed in the late monographs on the subject,
especially the one by Wollenberg in Nothnagel's series.'" But
it may be of interest to point out that our views in regard to

»» Edinburgh Med. Jour., October, ISGS, p. 294. Med. Times and
Gazette, 1869, March 6.

51 Brit. Med. Jour., 1869, April 9, 34.5 and 369.

2»Medieo-Chir. Trans., London, 1876, p. 1.

53Med. and Cliir. Trans., London, 188.5, vol. Ixviii, p. 277.

^* Lancet, 1885, vol. i, p. 985, and in other journals.

« Lancet, 1886, vol. i, p. 10.

"Specielle Path. u. Therapie, Bd. xii, ii, Th. 3d Abth.

the localization of the morbid process upon which choreic
movements depend, follow directly upon our physiological
belief. This must be so, for, as yet, pathological examina-
tions have given us no definite data. Hughlings Jackson,
Broadbent and others placed the lesion in or near the corjjora
striata or optic thalami, for at that time it was believed that
the movements of the body were coordinated in these struc-
tures. As our knowledge of the cortex increased, it was
demonstrated that coordinate movements could be elicited
by irritation applied to special areas of this structure and
that the destruction of these areas caused paralysis of the
movements. These most interesting discoveries directed the
attention of the whole medical world towards the brain cortex
almost, one is tempted to say, to the exclusion of the rest of
the brain. Every disease in which abnormal muscular move-
ments were a prominent feature was believed to depend upon
some lesion of the motor cortex. Chorea was among the
others, and at present the general opinion is that the wild
movements of the disease depend upon some morbid process
acting on the cortex. Of late, however, physiologists have
been calling attention to the very important part that sensory
impulses play in the production of coordinate movements, and
to the extreme complexity of the mechanism underlying such
movements. Destruction of many parts of the nervous system
other than the so-called motor tracts causes marked dis-
turbances. Ataxia, due to disease of the sensory spinal roots
and of the sensory path within the central nervous system;
experimental paralysis, caused by cutting the afferent roots
of a limb; the forced movements and paralysis following
destruction of parts of the cerebellum, may be mentioned
as examples.

It is quite conceivable that an irrit.ative lesion, or indeed,
a destructive lesion, acting on some one or more of these
structures might cause the involuntary incoordinate move-
ments so characteristic of chorea. But at present the facts
are too few to permit of anything more than a suggestion as
to the direction in which the lesion is to be looked for.
There are certain things that make it difficult to believe that
it is a disease of the cortex, especially the motor cortex, that
is responsible for the movements in chorea. That irritative
lesions of this structure are followed by abnormal muscular
movements, is one of the best established facts in pathology
of the nervous system; but the movements which have been
proved to follow lesions of the cortex are not at all like
those seen in chorea, but follow the general type of epileptic
convulsions; and, on the other hand, it is remarkable how
very uncommon it is for such convulsions to occur in chorea,
even in the most intense cases. In the slow systemic degen-
eration of the motor path, as it occurs in progressive central
muscular atrophy (amyotrophic lateral sclerosis) incoordinate
uuiscular movements, either voluntary or involuntary, are not
lircsent, tlie well-known fibrillary tremor being of quite a
different character. In certain cases of hemiplegia and di-
plegia in children, movements develop whicli are, at times,
(|iiile like those seen in chorea, and this would seem to lend
force to the belief in the central origin of chorea, or at least

OCTOBEE, 1901.]

JOHNS. HOPKINS HOSPITAL BULLETIN.

325

to the view that the motor path is involved. In some snch
cases, however, lesions have been found in the central gan-
glia, especially in the optic thalamus, and it is upon these that
most authors believe that the post-paralytic chorea depends,
and not upon lesions of the pyramidal tract.

Therefore, if these eases have any significance in explain-
ing Sydenham's chorea, they point to some structure other
than the motor cortex and the fibres leaving it, as being at
the root of the trouble — possibly to the optic thalamus. One
is tempted to assume, as did Hughlings Jackson and Broad-
bent long ago, although for quite different reasons, that the
morbid agents underlying chorea act upon the central gan-
glia. Of the functions of the corpora striata practically noth-
ing is known, but anatomical investigations make it seem
very probable that in the optic thalami sensory or afferent
imjiulses are rearranged before being distributed to the cortex.
It is easy to imagine that a lesion here could so disarrange the
afferent impulses passing through it that the voluntary move-
ments depending upon these impulses would be incoordinate
or, indeed, that involuntary incoordinate movements might
result. But, as I said before, the anatomical basis which
underlies coordinate muscular movements is extremely com-
plex and is, as yet, but partially known. It therefore seems
but of small value at the present time to advance any theory
as to the seat of the morbid process of chorea.

I cannot resist the temptation, however, to express my
conjecture that when the lesion is foiind, it will be on
the afferent rather than on the efferent side of the motor
mechanism.

In regard to the morbid agent, I have but little to say.
The objection to the embolic theory seems so strong in the
light of our present knowledge, that I do not see how it
can be held. The cases of embolism in the central retinal
artery during an attack of chorea demonstrate that such
emboli are at times present in the circulation of choreic
patients, which is no more than would be expected when we
consider how common endocarditis is in association with this
disease; but they cannot be made to prove that the disease
depends upon emboli in some other part of the brain — indeed,
what is strange is the great rarity of emboli of all kinds
in chorea.

The belief which is common now differs but little from
that held in the early part of the last century, when the
rehition between chorea and rheumatism was so strongly
urged. It was then thought that joint affections, endocar-
ditis and chorea were all different manifestations of the poison
upon which inflammatory rheumatism depends. Now we
Would say that the poison is similar to the rheumatic poison
and so avoid the definite statement that it is the same Wollen-
berg, who calls the disease infectious chorea, thinks that it
practically always follows some form of rheumatic infection,
and bears to this the same sort of relation that the paralysis
following diphtheria does to the diphtheritic infection. He
speaks of it as a meta-rheumatic process.

Discussion."

Ophthalmoscopic Appearances.

De. Eeik. — Through the kindness of Dr. Thomas I had
the privilege of seeing this patient and the opportunity of
sketching the ophthalmoscopic appearances. Perhaps a word
in explanation of, and apology for, this colored sketch should
be given before passing it around. The members of this
Society are so accustomed to the artistic work of Brodel and
Becker that one naturally hesitates to exhibit the efforts of
an amateur. The endeavor to illustrate some of the main
features of the ophthalmoscopic picture of this eye has, how-
ever, I hope, been sufficiently successful to serve its purpose
of aiding you to understand the conditions described.

You will observe that the central retinal artery, as it
emerges from the central canal is very small and its branches
appear like fine red lines as they spread oiit in the retina.
Their lumen has not been entirely obliterated, although the
contraction has reduced them to almost capillary dimensions.
The vessel walls are distinctly recognizable for a short dis-
tance beyond the disc margin by the delicate white lines
bordering the narrowed red column. The superior, nasal and
temporal branches can be traced quite to the periphery and,
after passing the first subdivision, it is noticeable that they
increase somewhat in size; possibly the result of anastomosis.
The inferior nasal branch is lost about 3 or 4 mm. from the
disc, being entirely invisible beyond that point.

The veins are somewhat smaller than normal and appear
to be slightly smaller on the papilla than towards the peri-
phery.

The optic disc shows a vrell marked atrophic condition and
its sharply defined edges are surrounded by an irregular ring
of choroidal pigment. The macular area is of deep red color
and the fovea is seen as a bright, but very minute, yellowish
spot. Between the macula and the disc, close to the former,
is a narrow semicircle of hazy white retina, with several
white dots to the temporal side. Pressure on the globe fails
to produce either arterial or venous pulsations. The eye is
absolutely blind. Taken in full the picture is a striking
one and typical of an obstruction in the central artery of the
retina.

The complete blindness which results suddenly from an
obstruction of this vessel is said to be permanent even
though the occlusion be but brief and be soon followed by
a restored circulation. A few hours only suffices to bring
about the functional death of the retina. If seen shortly
after the embolism occurs the arteries are seen as narrow
white bands, or as thin red lines on the disc, which are not
visible far beyond its margin. Within a few hours the retina
becomes generally hazy, and, in its thickest portion, between
the disc and macula, of a denser fluffy-white character, the
result of odema or possibly post-mortem changes. The
macula itself appears of a deep red color in marked contrast
to the pale surroundings. This has been said by some to be

" Meeting of the Johns Hopkins Hospital Medical Society, February
18, 1901.

326

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 127.

due to hemorrhage, but it is more likely only the appearance
of the deep red choroid seen through the retina at this point
and contrasted with the pale fundus.

At a later stage the vessels again become visible and are
seen to carry a thin stream of blood; the obstruction has
either been incomplete, the embolus has shrunken and allows
some blood to pass, or a collateral circulation has been estab-
lished. It has been generally held that the retinal is a ter-
minal artery and that anastomosis with the choroidal or
ciliary systems is impossible. Leber was unable, by injection
experiments, to demonstrate any connection between these
systems and the establishment of a collateral circulation has
never been proven post-mortem, still certain clinical evidences
seem to support the view that it may occur. For instance,
the arteries, as in this case, may appear larger in the peri-
phery than towards the disc, and in some cases observed by
Hirschberg and others, the blood current has been seen to
move towards the disc. Such a collateral circulation can
only come from the short ciliary arteries which sometimes
send branches, the cilio-retinal arteries, to the temporal side
of the disc, or from the long anterior ciliary vessels in the
sclerotic and choroid. In this case there are no such vessels
visible on or near the disc, but the distal parts of the superior
retinal arteries do appear to be somewhat larger than their
proximal ends.

Dr. Eandolph. — I was much interested in Dr. Reik's de-
scription of this case, particularly in regard to the cherry-red
spot in the neighborhood of the macula. I think the most
reasonable explanation of it is to be foimd in the condition
of the retina at that point. In the region of the macula
lutea, the retina is thinner than anywhere else and we can
easily understand that the red color of the choroid seen
through this thinner area would be more emphasized at this
point than elsewhere. This is the case in the normal eye.
I think, as Dr. Eeik said, that it could not be due to hemor-
rhage. One of the particular points of difference between
embolism of the central artery and thrombosis of the central
vein is the absence of hemorrhages in the former affection.
In thrombosis hemorrhages are always seen. I think, then,
the red spot is due to the thinner retinal tissue in this region
and this color is of course much accentuated by the anemia
of the surrounding retina.

De. Oslee. — It is surprising that embolism does not occur
oftener in chorea; perhaps there is no disease in which endo-
carditis occurs more frequently. Some 6 or 8 years ago I
took the trouble to go over 73 comparatively recent autopsy
reports in chorea cases, in 67 of which endocarditis was pres-
ent and yet embolism is certainly rare. In one of the five
autopsies in chorea I found a spot of embolic softening in the
corpus striatum.

VOLVULUS OF MECKEL'S DIVERTICULUM WITH RECOVERY AFTER OPERATION.

By William J. Tatloe, M. D., Philadelphia.

Attending Hurijcon to St. Agnes' Jlvspital and to the Orthopedic Hospital and Infirmary for Nervous Diseases. Consulting Surgeon to the West

riiiladelphia Hospital for Women.

A little girl, aged six, was admitted to St. Agnes' Hospital
late in the afternoon of Wednesday, April 11, 1900. The
family history was negative, except that a brother had been
operated upon for an acute appendicitis.

All her life long she has been subject to occasional attacks
of abdominal pain which had always been relieved by a pur-
gative. On April 9, 1900, she was seized with sudden and
acute abdominal pain and was under the care of her family
physician who was vmable to open the bowel by ordinary
measures. This condition persisted, and she was admitted to
the hospital on the afternoon of April 11, forty-eight hoiirs
after the beginning of the attack. I saw her within an hour,
when she had the appearance of being extremely ill with a
temperature of over 100° F., intense pain and marked rigidity
of the abdominal muscles, and a rapid and very weak pulse.
Presuming from the history and her physical condition that I
had to deal with an attack of acute appendicitis, and the
rigidity of the abdominal wall being such that I could not
make a careful examination, she was immediately etherized

■Read before the Johns Hopkins Hospital Medical Society, February
18, 1901.

and the abdomen opened by a small incision in the right side.
Introducing my finger, a tense rounded mass was perceived,
filling the whole of the right side of the pelvis, resembling
somewhat an enormously distended intestine, and upon en-
larging the wound I could see a dark, almost black, ill-
smelling mass. The intestines were so much distended that
I was obliged to open the ileum at one place to get rid of a
large amount of gas and liquid fa3ces before I could bring
the intestines under control. This I consider a much safer
proceeding than evisceration, especially in young children
who bear such manipulations badly. I then enlarged the
wound and, after some difficulty, delivered a dark-colored,
almost gangrenous, cystic tumor, whicR upon careful investi-
gation proved to be a Meckel's diverticulum, springing from
the wall of the ileum farthest away from the mesentery and
about fourteen inches from the cajcum. One inch from the
intestine proper, the pedicle of the diverticulum had twisted
upon itself three complete turns, thus cutting off the circula-
tion and causing it to become gangrenous. The distended
end of the diverticulum was about the shape of a potato
with a pedicle not larger than a lead pencil at the point
where the twisting occurred, and was entirely free in the

October, 1901. J

JOHNS HOPKINS HOSPITAL BULLETIN.

327

abdominal cavity, except at its point of attachment to the
ileum. There was no evidence of a cord-like remains of the
diverticulum nor of the omplialo-mesenteric vessels. There
were no adhesions of any moment holding the cyst, if it can
lie so called, in place, but the whole of the pelvis was filled
witli it. Tile rough measurements of this mass were 3|
iiiclies long by 2 inches wide. This small pedicle was grasped
uith a clamp forceps, and it was then cut away from the
intestines through sound tissue, tlie wouiul invaginated, and
closed with a double row of Lembert sutures. It was neces-
sary to almost completely eviscerate the child before this
mass could be delivered through the abdominal wound. The
intestines were much congested and at several points were
covered with patches of lymph and several coils were glued
together by adh(>sions. The glands in the mesentery were

I'botograph uf .Meckel's Diverticulum, natural size. Showiiijc the
pediele i^rasped by clamp forceps.

enlarged and hard, several being the size of a lima bean, liut
tlie majority were not larger than a pea. In view of the
gangrenous condition of the cyst, a small rubber drainage
tube was introduced after free flushing of the abdominal
cavity with a saline solution. The pedicle was so softened
that in examining the diverticulum after its removal, its wall
burst and quite an amount of its contents — which consisted
of fluid fseces — escaped. This photograph taken by flash
light was made within a few minutes after its removal and
shows admirably both its size and appearance, although,
owing to the escape of some of its contents, as I have just
stated, the distension of its walls is not so great as at the
time of its removal.

The greatest haste possible with accurate work was em-
[iloyod during the operation which jiroduced profound shock.

Reaction occurred very quickly, however, and convalescence
was rajiid and uneventful. She was discharged from the
hospital at the end of three weeks.

This case was absolutely unique in my experience, as from
the history, the symptoms, and the examination of the child
before operation, I had no douljt but that my diagnosis of
an acute appendicitis was correct, while she was too ill and
her symptoms too urgent for any elaborate physical exami-
nation. At first I was utterly at a loss to explain the cystic
mass which I could feel within the pelvis and. iiideiHl. I
suspected it to be an ovarian cyst which had become strangu-
lated. . The cause or mechanism by which the diverticulum
became twisted u]ion itself is quite hcyond my explanation,
but it is possilile that the peristaltic movements of the intes-
tines may account for its occurrence.

In making a somewhat extended search of the literature
of the subject of ileckel's diverticulum and its relations to
intestinal strangulation, I can find no record of an exactly
similar case. E. H. Fitz in his exhaustive study' does not
record a similar instance, but J. W. Elliot ' reports one very
much like it, discovered in operating upon a sup])osed case
of acute appendicitis. In this instance, the diverticulum
was about seven inches long and of the diameter of the ileum,
and had become twisted upon itself at the attachment to the
gut and |u'o(hiced strangulation. This ease recovered. J. A.
Prince ' records an instance of a child, aged four years, who
liad colic for three days, when by abdominal section a diver-
ticulum was found of globular shajie, one-quarter inch in
diameter at its junction with the intestine, five-eighths of
an inch in its greatest diameter, and ending in an elongated
cord. Perforation had occurred. T. L. Kelynack ° records
a largely distended diverticulum, a s]iecimen in the Patho-
logical Museum of the Manchester Royal Infirmary. In 1440
subjects examined by him post-mortem, IS examples of-^
Meckel's diverticulum were found; this gives a proportion of
1 to 80, or about 1.25 per cent. It was more common in
males than in females in the ]U'o])ortion of 11 to T. The
oldest of all these cases was 60, the youngest 13. In no
instance was the presence of the diverticulum in any way
connected with the cause of the death of the subject. The
photograph wliicli he shows in his article was from a patient,
aged 42, who died of acute pneumonia. The diverticulum
was connected with the ileum by a narrow mouth, ^ of an
inch wide, and then extending to a diameter of an inch and
rapidly widening into a pouch almost as big as the coecum.
It had a diameter of 3^ inches and a circumference of lOJ
inches. It lay quite free in the abdomen and, possibly, its
large size may have been due to distension by the intestinal
contents. In no instance in all the 18 cases which he records
was the lumen of the diverticulum continued to the umbilicus
or the abdominal wall. In tlio Manchester Med. Chronicle

2 Am. .Jl. Med. Sc, .July, 1884, p. 30.
'Boston M. & S. Jl., June 14, 1894, p. .586.
•• Medical News, January 14, ISn.S, p. 4.'i.
iiBrit. Med. Jour., Ana:. 31, 1S!I7, p. l.^il.

328

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 137.

(1SS)(;, p. 338), he mentions also an instance of a pendulous
pear-shaped jioueh, discovered after death from sarcoma of
the thii;h. Thomas C'arwardine ° reports a case of volvulus
of Meckel's diverticuhnu occurring in a child two days old.
The child had heen repeatedly sick, bringing up a greenish-
brown vomit and had passed nothing per anum, nor was there
any discharge from the umbilicus. The distension apjaeared
more on the left side and upon opening the abdomen, there
were evidences of lymph upon the surface of the distended
intestines from peritonitis and there were numerous adlie-
sions. In making an artificial anus into a mass on the right
side of the abdomen, a considerable quantity of meconium
escaped. The child died in twenty-four hours, and upon
post-mortem examination, it was found that a meconium-
containing cyst had been opened, produced by volvulus of
Meckel's diverticulum of some three turns, (^nly a small
impervious cord connected it with the bowel below and a
minute stalk, which would partially admit a bristle, attached
it to the distended bowel above, the junction being a T-shaped
one. The sjiecial point of interest in this case is the volvulus
of the diverticulum occurring in late fcetal life in utero.
Lionel Beale ' describes a case of death due to ])erforation
of a Meckel's diverticulum, fifteen inches from the ca3cum.
This was nearly three inches long, about the same diameter
as the bowel at its origin but increased in size until it termi-
nated in a cul-de-sac, lieing twice as broad at its lower ]iart
as at its origin. It contained a cherry stone and other
foreign substanci's.

Numerous instances of strangulation of the bowel due to
the diverticulum being attached to other organs and to the
liands fornuMJ by the persistence of the omphalo-mesenteric
vessels have been re])orted by D. P. Allen," .\. V. iEcGill."
C. E. Darnall,'" and many others, while quite a few instances
have l)een known of an intussusception having its origin in
an invaginated ileckefs diverticulum, as in James Adams' "
ease and in those mentioned by Treves in his " Intestinal
Obstructions," and by others. H. H. A. Beach '" mention^
an instance of pelvic tumor formed by a calcified Meckel's
diverticulum uniting the ileum and the Idadder.

I have iiurposely not gone into the anatomical and patho-
logical details of these interesting eases, nor have I attempted
to tabulate all those which have been reported, merely men-
tioning a few of those which have seemed to more nearly
resemble my own. Fitz " mentions one case reported by
Both — I have not been able to consult the original reference
— in a child a year and a half old. where the pedicle became
twisted and hemorrhagic infiltration and necrosis of the
mucous membrane occurred with acute peritonitis. He men-

*Brit. Med. Jour., 1S97, December 4, p. 1637.
1 Path. Soc. Trans, vol. iii, p. 366. May 4, 18.52.
8 Med. News, Auff. 13, 1892, p. 177.
»Brit. Med. Jl., January 14, 1888, p. 72.
>»N. T. Med. Jl., January 12, 1901, p. 62.
"Brit. Med. Jour., April 9, 1892, p. 764.
'-Annals of Surgery, October, 1896, p. 484.
'3 Am. Jl. Med. Se., July, 1884.

tions also several instances of cyst connected \vith the intes-
tine which umloul>tedly originated as diverticula, and it is
to this very elaborate pa\)QV I W(nilil refer as well as to
Doctor Osier's paper in the Annals of Anatomy and Surgery,
1881, Vol. lY, and particularly to Frederick Kammerer's in
the Annals of Surgery, August, 1897.

The cyst contained two grains of corn, two half peanuts
and a fluid, greenish in color and of very foul odor.

Discussion'.

Dr. Kelly. — Diseases of Meckel's diverticulum, apart
from hernia, are certainly rare; in the course of several thou-
sand abdominal sections I have never seen one pathological
diverticulum. I am interested in this case ])articularly on
account of the twisted pedicle, the occasion of operation; the
torsion of abdominal organs or tumors is a subject still Imt
inditTerently understood.

There are undoubtedly a variety of factors which may
operate to produce a change of position and hence sometimes
of rotation of a body or viscus contained within the abdomen.

I think, further, that the subject of rotation should not b,_'
considered alone, but should rather be studied in connei'tion
with various other movements, especially those of accommo-
dation or of adaptation of the contained structure to the
space in which it is contained, then understanding the various
movements which may be imiu'essed upon all bodies we are
better jircfiared in any particular case to e.\]ilain the cause of
the rotation. A lack of employing this wider method of
analysis is manifest in the common mistake of trying to
explain the rotation of all tumors by one rule often known
by the name of an investigator. The following factors must
be considered :

1. A growth of the tumor and a consequent change in size
and form necessitating change of position.

2. Spontaneous movements on the part of the tumor, as in
the case of the lump fetus.

3. Movements impressed iqion the tumor by the surround-
ing hollow viscera or the growing uterus.

4. Movements iinju'essed on the tumor by the contraction
and relaxation of the abdominal parietes.

5. Movements resulting from translation or suceussion of
the body, as in walking, lying down and rising, ascending
steps, etc.

The position of the body in the abdomen and the character
of its pedicle are also factors of the utmost importance.

For example, a long thin pedicle which offers no resistance
is best adapted for displacement as well as for the torsion
of the body attached to its extremity. A short thick pedicle
offers resistance and sessile bodies manifestly cannot be
twisted at all.

A body attached somewhere at the periphery is less liable
to displacement than one situated more centrally; it is for
this reason all the heavier viscera are attached to the walls
on all sides, while the intestine designed physiologically to
enjoy a wide excursus of movement, is centrally placed with
a mesentery which acts like a pedicle.

October, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

329

Examples of rotation are oftenest found in ovarian tumors
which do not conform to the physiological type of the viscera
either in their location, for they soon grow out among the
moving viscera, or in~the nature of their attachment, which
instead of being sessile is by a more or less attenuated pedicle.
There are three important phases in the life history of an
ovarian tumor in this connection; in the first place, as it
grows it fills the posterior quadrant of the pelvis in which it
lies, often pushing the uterus in the opposite direction; next
it fills the whole posterior pelvis and projects up through
the superior strait; finally, it ends by filling the abdomen
more or less completely. While in the pelvis the tumor rarely
rotates, as it is splinted on all sides by the pelvic walls, and
the largest tumors rarely rotate as they, too, are splinted by
the abdominal walls and are too heavy to be impressed by
slight forces. I find that the larger cysts are oftener accom-
modated on the right side imder the liver, and I attribute
this to the repeated soft impacts of the alternately distending
and contracting stomach.

The medium sized ovarian tumors are the ones oftenest
twisted, and I consider two factors of great importance in
this connection; one is the constant movements of the viscera
now collapsed and now distended with food and gases, especi-
ally the movements of the stomach; the other is the nipping
action of the linea alba on one side of the tumor or the other
as it lies in one or other iliac fossa. As the abdominal walls
contract the linea is brought nearer to the bodies of the
vertebra and the tumor is caught on one side and the ten-
dency is to turn it.

It is well known that a large percentage of cases of twisted
pedicles occur after a confinement; here a most interesting
new factor steps in, and that is the sudden translation of the
tumor drawn by the collapsed uterus into a new environment.
Given an irregular body (tumor) lying within an irregular
cavity (abdomen), and granted certain movements, the con-
tained body will seek that position in the container which is

best adapted to its form. It is during this period of re-
adjustment after pregnancy that torsion occurs.

I have spoken in my second rule of spontaneous move-
ments on the part of the tumor (living fetus) deciding its
relation to the container (uterus), and this, I think, explains
the reason for the position of the fetus in utero.

Dead fetuses oflier a large percentage of breech presenta-
tions, and this is due to the fact that the relation of the living
fetal ovoid to the uterus is not simply that of the actual phy-
sical measurement, as in the dead, but is the potential ovoid
of the body plus the excursions of the feet. If we enlarge the
caudal pole of body by adding the segments of circles de-
scribed by the feet, we will then have a figure corresponding
in form to the interior of the uterus distended with the
normal amount of liquor amnii, and the reason of the usual
inverted posture is evident.

De. Mitchell. — During the last year there has been in
Dr. Halsted's service a case which might be of interest in
connection with that of Dr. Taylor.

A boy, four years old, was admitted with a strangulated
left inguinal hernia. The hernia had been present about a
year. The patient was in good condition. On five or six
previous occasions there had been difficulty in reduction, and
the present strangulation had existed twenty-six hours, being
accompanied by great pain, and for the past sixteen hours
frequent vomiting. Operation was performed immediately
imder chloroform ana?sthesia. In the hernial sac was found
a loop of ileum 6 or 8 cm. from the caecum, and by its side a
Meckel's diverticulum, both being constricted at the external
ring. The diverticulum was 5 cm. long, 2 cm. in diameter
at its base, and 1 cm. in diameter at its tip. The distance
of its point of origin from the csecimi was not determined.
The cfBcum and appendix were presenting just within the
external ring. The diverticulum was excised, the bowel
dropped back, and the radical operation for the cure of hernia
performed. Eecovery was uneventful.

HOSPITAL STAFF OCTOBER 1, 1901.

Superintendent :
HENRY M. HURD, M. D.

Pht3Ician-in-Chief :

WILLIAM OSLER, M. D.

Sdrgeon-in-Chief :

WILLIAM S. HALSTED, M. D.

Gtnecologist-in-Chiep :

HOWARD A. KELLY, M. D.

Obstetricianin-Chief :
J. WHITRIDGE WILLIAMS, M. D.

Pathologist:
WILLIAM H. WELCH, M. D.

Associates in Surgery:
J. M T. FINNEY, M. D., J. C. BLOODGOOD, M. D.

Associate in Medicine:
W. S. THAYER, M. D.

Associates in Gtnecologt :
W. W. RUSSELL, M. D., T. S. CULLEN, M. B.

Resident Physician:
T. McCRAE, M. B.

Assistant Resident Physicians :
R. I. COLE, M. D., C. P. EMERSON, M. D.

Resident Surgeon :
J. F. MITCHELL, M. D.

Assistant Resident Surgeons :

R. H. FOLLIS, M. D., M. B. TINKER, M. D.,

W. F. M. SOWERS, M. D.

Resident Gynecologist:

G. L. HUNNER, M. D.

Assistant Resident Gynecologists :

B. R. SCHENCK, M. D.,* J. A. SAMPSON, M. D.,

C. F. BURNAM, M. D.*

Resident Obstetrician:

F. W. LYNCH, M. D.

Resident Pathologist:

W. G. MacCALLUM, M. D.

Assistant Resident Pathologists:

E. L. OPIE, M. D., W. B. JOHNSTON, M. D.

House Medical Officers :

F. H. BAETJER, M. D.,
T. R. BOGGS, M. D.,
J. I. BUTLER, M. D.,+
R. F. HASTREITER, M. D.,
J. M. HITZROT, M. D.,
J. M. SLE.MONS, M. D.,
L. M. WARFIELD, M. D.,

EXTERNES :

MABEL WELLS, M. D., C. K. WINNE, M. D

J. M. BERRY, M, D.,
C. H. BUNTING, M. D.,
H. A. FOWLER, M. D.,
J. H. HATHAWAY, M. D.,
M. J. RUBEL, M. D.,
C. N. SPRATT, M. D.,
S. H. WATTS, M. D.

♦Absent on leave.

tAuting.

330

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 137.

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CONGENITAL ABSENCE OF THE ABDOMINAL MUSCLES, WITH DISTENDED AND HYPER-

TROPHIED URINARV BLADDER.

By William Osleh, M. D.,
Professor of Medicine, Johns Hopkins University.

In the summer of 189? a case of remarkable distension of
the abdomen was admitted to the wards, with greatly dis-
tended bladder, and on m_Y return in September, Dr. Futcher,
knowing that I would be interested in it, sent for the child.
The accompanying figures, I and II, from photographs, show
a very remarkable and unusual pattern of " abdnniiiiiil tumid-
ity," differing in an interesting way from the piriiive of the
dilated colon in children, and rescmliling rather that of the
ascitic abdomen.

The examination showed that the eliild liad practically
no abdominal muscles.

On looking up the literature I can find reports of only two
similar cases. In the Clinical Society's Transactions (Vol.
28, 1895), K. W. Parker describes the condition of a newly
born infant, weighing five and a half pounds, with a very
large, flaccid abdomen, through which the outlines of the in-
testinal coils could be clearly seen, and the outlines of the
abdominal organs easily felt. The abdominal wall was as
thin as parchment. Along the middle line, where the rectus
muscles should be found, there was little more resistance
than over the lateral regions. The oblique and transversalis
muscles were apparently quite undeveloped. The umbilicus
was not depressed, it was in normal position, but resembled a
surface sear. The child died not long after birth. There

was no trace of any muscle representing the transversalis ab-
dominis. There was a thin layer of muscular fibres passing
from the cartilages of the ribs to the level of the eighth costal
cartilage, where there was the first linea transversa. The
body of the muscle was well marked on the right, but on the
left it w'as but faintly seen. Further down there was the mer-
est trace of muscular fibres, representing the rectus on either
side. The most remarkable associated condition in this case
was the enormous hypertrophy of the bladder, which was
situated wholly within the abdominal cavity. There was no
obstruction anywhere in the urethra or prepuce. The open-
ings of the ureters into the bladder were quite free. The
ureters and pelves of the kidneys were greatly dilated and
hypertrophied. /

In 189G, Dr. Leonard Guthrie reported to the Pathological
Society of London (Transactions, Vol. 47), the history of a
male infant, aged nine weeks, pigeon-breasted, very bony
and emaciated, with a greatly distended abdomen. Extend-
ing between the pubes and the white, linear cicatrix corre-
sponding to the umbilical scar there was a smooth, elastic
tumor, corresponding to a distended gall-bladder. The ab-
dominal walls were excessively thin and loose, and seemed to
show the coils of the distended intestines on either side, but
post-mortem these coils which looked like the intestines

332

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

proved to be the uiiormouply dilated and convoluted ureters.
The liver, spleen and kidney* could be easily palpated. The
child wasted rapidly and died when about ten weeks old. Of
the recti only the two upper segments as far as the second
linea transversa showed muscular fibres. Below this level
no trade of muscle could be discerned. The costal origins
of the obliqui and transversalos showed muscular structures
for about two fingers' breadth below the ribs. The muscles
of the back, of the thorax ajid of the extremities were well
developed. Here again the most remarkable features related

Fig. 1.

to the urinary organs. The bladder reached as high as the
scar of the navel, and the walls were a quarter of an inch in
thickness. The ureters were dilated to the size of the small
intestines of an adult, and were remarkably tortuous. After
death they exactly resembled, and at first were taken to be,
portions of distended small intestine, as they were thought
to be when seen through the weakened abdominal walls dur-
ing life. The orifices of the ureters into the bladder ad-
mitted a blow-pipe. There was no obstruction in the ure-
ters; there was no stricture of the urethra, and no phimosis.
The kidneys were not enlarged, but the pelves were dilated.
The position of the testes was not stated.

An important point in Dr. Guthrie's case was that there

was no trace of a urachus, and the bladder was closely ad-
herent to the inner surface of the umbilical scar, so much so
that it could not be removed without the scar and the adjoin-
ing portions of the abdominal skin.

The history of my case is as follows:

Claudius K., aged 6, admitted July 13, 1897, complaining
of stomach trouble, and difficulty in passing the urine. The
chest has been deformed, the mother says, since birth.

The family history is good. One other child; well and
strong; parents are health}'.

^^BB

• )

Fig. 3.

Personal History. — The child was well until the second
summer, when he iad severe stomach trouble. There have
been recurrences of these attacks each year. From the ac-
count some of them have been gastric attacks, with naiisea
and vomiting, but others, and apparently the chief troubles,
have been with the urine. The spells last four or five weeks,
and they have beer getting more frequent. In the intervals
he is pretty well and strong, and hn.^ a large appetite.

His present attack began about a week ago, and he com-
plained of pains in the abdomen and much burning sensation
in passing water. He has become very weak; has not had any
vomiting. He has had some headache.

The patient was a poorly nourished child, looking anaimic.

NOVEMBEB, 1901. J

JOHNS HOPKINS HOSPITAL BULLETIN.

333

He complaiued of much pain, chiefly in the hypogastric and
lower umbilical regions. On inspection the condition to be
described was noted by Dr. Futclier, but in particular there
was a remarkable fulness in the hypogastric and lower um-
bilical regions, which were occupied by an ovoid mass cor-
responding to a dilated bladder. The urine which was ob-
tained by catheter was free from albumin, contained a good
many leucocytes. The child had a temperature ranging from
99° to 108°. He passed the urine very frequently, an aver-
age of from 60 to 70 cc. In the twenty-four hours ending
3.30 on July 13tli he passed urine 20 times, a total amount
of 1090 cc; on the 14th he passed urine 18 times, a total
amount of 835 cc; on the 15th he passed urine 15 times, a
total of 1060 cc.

The condition was so unusual that on my return in
September the case was sent for, and on the 8th I dictated
the following note:

In the erect posture the attitude is verj remarkable. It
is not quite .symmetrical, being fuller on the right side than
ini the left. The navel looks stretched and distended. It
is linear, forming a furrow about an incli iu length, and below
it are furrows in tlie skin — crow"s feet. Above there is seen
distinctly on either side the attachment of the recti to the
sternum and costal margin. The skin over the abdomen is
thin; the veins are a little prominent. When he bends back
slight movements of the abdominal muscles beneath the skin
are seen.

Eemnibent. — Belly flattens out in front, extends at the
flanks. Coils of intestines can be seen in peristalsis. Ex-
treme relaxation of abdominal walls; no resistance; fingers
can be passed everywhere to the spine. Three fingers can be
jiassed under costal margin over liver nearly 6 cm. The
edge of the liver can be felt in its whole extent, and the
fingers can be thrust almost as far under it. The bladder
could be felt as a firm ovoid body, reaching almost to the
navel.

Spleen can be felt on deep pressure. Both kidneys can
be felt.

He cannot raise himself off the bed without turning over.
As he makes the attempt the abdomen is thrust forward and
slight contraction is seen of the expanded abdominal muscles
and recti.

The deformity of the thorax is very remarkable. Harri-
son's grooves are unusually marked, corresponding to the 6th
costal cartilage. The lower portion of sternum is thrust for-
ward, forming almost a right angle with the xiphoid carti-
lage. As shown in the photograph it is remarkably promi-
nent, and is fully 3 cm. above the level of the skin in the
intercostal furrows.

There is a condition of cryptorchidismus. The testes are
not to be felt in the groins.

Eemarks. — These cases illustrate a very remarkable form
of congenital defect. The deficiency in the abdominal mus-
cles, and the high position of the bladder are associated condi-
tions due to arrest of development. We could not say definite-
ly in my case whether the bladder was adherent to the umbili-
cal scar. Ur. Guthrie regarded the hypertrophy of the blad-
der and the dilatation of the ureters as secondary, due to the
fact that in his case, being firmly connected with tlie iimbili-
cal scar, it was imable to contract downward and to empty
itself completely. In its effort to do so it became hyper-
trophied and dilated, and the accumulation of urine caused
backward pressure and dilatation of ureters.

In reply to a c[uestion. Dr. Bardeen, one of Prof. Mall's
associates in the Anatomical Laboratory of the Johns Hop-
kins University, who has been specially engaged in a study
upon the development of the muscles, writes as follows:
'■' Two possibilities suggest themselves to me in the case:

"1. It is possible that the lack of resistance normally met
with in the abdominal wall by the bladder at the time the
kidneys begin to secrete urine may' cause the bladder to
expand rather than to empty secretions into the amniotic
cavity through the urethra.

" 2. Under normal conditions the growth of the abdominal
musculature into the ineiiihraiia reunieiis, the early covering
of the abdominal cavity, is preceded by the formation of a
vascular plexus supplied from above by the internal mam-
mary, from below by the epigastric artery. It is possible that
an abnormal arrangement of the blood vessels in the embryo
prevented the formation of this plexus, and impeded the
growth of the abdominal musculature, and that at the same
time circulating disturbances gave rise to the abnormal con-
ditions found in the bladder and ureters."

ON A FAMILY FORM OF RFCURRTNrx EPISTAXIS, ASSOCIATED Wmi 31ULTIPLE TELAN-
GIECTASES OF THE SKIN AND MUCOUS MEMBRANES.

By William Oslek, M. D.,
Professor of Medicine, Johns Hopkins VniversHy.

The association of epistaxis with angiomata of the nasal
septum has long been known; but for the associated con-
dition of multiple telangiectases of other mucous membranes
and of the skin, I have been able to find only the following
report by Rendu." A man, aged 52, whose father had had

The association here described is rare, as, after a careful
search through the literature, I can find but one reference
to a similar case.

An hereditary form of epistaxis has been well described
by Babbington.'

' Lancet, 186.5, ii, p. 362.

sGaz. dea Hopitanx, 1896, p. 1332.

334

JOHNS HOPKINS HOSPITxVL BULLETIN.

[No. 128.

repeated attacks of inclena, and whose mother and brother
had been subject to cpistaxis. was admitted in a condition
of profound anremia, liaving liad tor three weeks a dail}'
reenrrence of epista.xis. He had Iiad his first attacks of
bleeding from the nose at the age of twelve, and had been
subject to them ever since, particularly in the spring. He
had never had any other hasmorrhages. On the skin of the
nose, of the cheeks and of the upper lip there were numerous
small red spots due to dilatation of superficial vessels of the
skin. Similar small telangiectases were seen on the internal
surfaces of the lips, the cheeks, the tongue, and on the soft
palate. The punctiform angiomas were not seen on the
mucous membrane of the nose.

In the three cases here described, two belonged to a family
in which epistaxis had occurred in seven members. Both of
my patients had had bleeding at the nose from childhood,
and both presented numerous punctiform angiomata on the
skin of the face and of the mucous membrane of the nose.

lips, clieeks and tongue.

The third patient had suffered in an unusual degree from
recurring epistaxis, and the telangiectases were most abun-
dant over the body, and very numerous also on the nnieous
membranes.

The condition has nothing to do with hemophilia, with
which the cases had been confounded.

Case I. — Allm-Ls of Epistaxis front hoi/liood : scrrn mein-
hers of the family subject to it. Telangiectases on shin, of face
and on mucous menihranes of nose and mouth.

George B., aged 57, a seaman by occupation, admitted to
the Johns Hopkins Hospital Hay 31, 1S9T, with anaemia and
swelling of the feet.

Family History. — The father died at 09, of stone in the
bladder. From boyhood at intervals he had had bleeding
from the nose, never, so far as his son knows, from any other
situation, nor does his son think that he bled specially from
cuts. The bleeding was very frequent, generally, the son
says, every day. So far as he remembers he never was in any
danger from it.

The mother, who is living and well, aged 81, has never
had epistaxis. He does not know of any members of his
father's or mother's families who were bleeders.

Brothers. — Two died suddenly, one aged 47, the otlier aged
57. Neither had ever bled from the nose. He does not
know the cause of death. The history of a third brother,
who has had epistaxis from boyhood, will be given subse-
quently.

Sisters. — One died at 59, of Bright's disease. She was a
large, stout woman, and had been subject to epistaxis from
childhood. A second sister, the mother of fourteen children,
died several years ago in childbirth. He does not know
whether it was from haemorrhage. She had bled from child-
hood both from the mouth and nose. He does not know
whether she had any " spots " on her nose or lips.

In the third generation, this patient has one child, aged 13,
who has bled occasionally from the nose. He has never

heard that any of his nephews or nieces have bled, but a
gTandniece, granddaughter of the patient's elder sister, has
had epistaxis frequently.

Personal history. — He had been a sailor for forty-three
years. He had been a moderate drinker. He had had syphi-
lis thirty years ago. With reference to the epistaxis, he does
not remember to have had it before his tenth year. The
attacks were not very severe, but recurred almost every day.
He was able to go to school, and later to his work. Twenty
years ago, when he was thirty-seven, the condition became
much more serious, and for nearly three years he was unable
to do any work on account of the weakness and anaemia
induced by the bleeding. He seems to have had a great deal
of prostration, and says that for nearly five months he could
not use his left arm. He has iu'\er bled from cuts, and
never from the gums. While in the Navy, in 18()3, he l)led
profusely from one of the angiomata on the lower lip, also
from a very small one on the skin of the septum. He has
frequently been very anannic, and has had swelling of the
feet and shortness of breath. He has had liEemorrhoids for
thirty years, and fourteen months ago had them removed at
the Marine Hospital. He has bled indifferently from right
or left nostril. Latterly the bleeding has become much more
aggravated, and he has become very annemic.

Present condition. — The patient was a large framed, well
nourished man, very intelligent. He was short of breath,
the face looked a little swollen, suffused and ansemic; the
feet and legs were swollen. The blood examination gave
2,980,000 red blood corpuscles, leucocytes 8000, ha3moglo]jin
between 15 and 20 per cent. The nostrils were very capa-
cious, and there was a clot of blood projecting from the left
orifice. He had bled up to time of admission. The coagu-
lation time as taken by Wright's tubes ranged from five and
a half to seven minutes.

The general surface of the skin was pale, a little yellow.
No liffmorrhages were seen except on the right elbow where
was a rounded area of subcutaneous extravasation about 1|
cm. in diameter. The face iDresented a very unusual appear-
ance, owing to the large number of dilated venules and
capillary and venous telangiectases. They were most abund-
ant on the ears, the skin of wdiich presented a remarkable
appearance, partly from the dilatation of the venules, which
could readily be seen, and partly from the bright red capillary
telangiectases. There were some dilated venules on the nose
and cheeks, and the lips present a number of angiomata,
particularly on the mucous surface, and just at the junction
of it with the skin. There w^ere one or two small ones about
the skin of the nostrils, and subsequent examination showed
numerous angiomata on the mucosa of the septum, particu-
larly on the cartilaginous portion.

The mucous membrane of the mouth looked normal, but
the tongue, on the tip and along the edge for a little distance,
sliowed a number of telangiectases.

There was no albumin in the urine; the specific gravity
was 1010, no casts. His legs were swollen to the middle of
the calves. There were dilated venules on the outer aspect

November, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

335

of the legs. The edge of the spleen eonld just be felt. The
liver was not enlarged. The apex beat of the heart was felt
just under the right nipple. There was a soft systolic mur-
mur at the apex, and a louder one along the left sternal
border. The bleeding stopped shortly after admission.

On May 25, he had a slight attack of epistaxis, which
lasted for thirty minutes. The general condition had much
improved. The cedema had disappeared from the extremi-
ties, and he had gained rapidly. The blood condition im-
proved, and on the 25th the red corpuscles were 3,224,000.

This patient has reported at intervals at the Dispensary
through 1898, 1899 and 1900. He has had bleeding from
the nose at intervals, lasting for a few hours at a time.
When last seen he looked very well, though a little anaemic.
There has been no sjiecial change in the cutaneous telangiec-
tases.

Case II. — Epistaxis from cliildhood; Telangiectases of sMn
and mvcous membranes, Heeding from some of the spots.
Cancer of the stomach, death, autopsy.

William B., aged 55, admitted Jan. 20, 1899, complaining
of stomach trouble.

Family History given with Case I.

Personal History. — He began to bleed from the nose very
early in life; he does not remember exactly the date. It has
been a source of constant trouble, and has on several occa-
sions caused extreme anaemia and weakness. He usually
bleeds without any provocation. He has never bled freely
from cuts, but on several occasions spots on the face have
bled after shaving, and he has bled from the red spots on
the lips. Of late years he has bled less frequently than
when he was a younger man. He has been a sailor, and has
led a very irregular life; has used tobacco freely, and has
been at times a very heavy drinker.

He came into the hospital complaining of nausea, vomit-
ing and pain in the abdomen, which he had had for some
months.

Present Condition. — The patient looked pale and sallow,
and there were numerous small varicose veins on the skin
and mucous membrane of the lips, and on the side of the
nose, a few on the cheeks and on the ears. On the tongue
there were a number of small red spots, evidently of the same
nature. The same spider-like angiomata could be seen on
the mucous membrane of the septum of the nose. They
were not so numerous nor so striking a feature as in his
brother's case, though those upon the mucous membrane of
the lips were large enough to at once attract attention. The
patient had a large tumor mass in the abdomen, evidently a
new growth of the stomach.

Blood examination the day after admission: r. b. c. 4,488,-
000; leucocytes 7490; haemoglobin 71 per cent. The blood
coagulation time on Jan. 20th was eleven minutes; on the
22d, it was eleven minutes; on the 2.3th it was eleven minutes;
on the 26th it was nine and a half minutes. He had repeated
bleedings, and then on January 31st the coagulation time

was four minutes. After he had been taking calcium chlo-
ride, fifteen grains three times a day for three days.

He bled freely from the nose two days after entering the
hospital, and was given 250 ee. of a one per cent gelatin
solution hypodermically. The blood coagulation time was
reduced to one and a half minutes.

On January 30th he had two bleedings from the nose, and
again on the 31st. On Feb. Cth he vomited coffee-ground
material. On Feb. 9th he had another bleeding from the
nose. On Feb. 10th the blood coagulation time was one
minute. On Feb. 18th he had a right hemiplegia. He grew
progressively weaker, and died on Feb. 24th.

The anatomical diagnosis was: cancer of the stomach,
mesentery, omentum, liver, retroperitoneal glands, kings and
brain. Angiomata in miicous membrane of the nose and of
the stomach. In the stomach there were a dozen round foci,
each 3 to 4 mm. in size, which at first looked like ecchymoses
but were dilated venules and capillaries.

Sections of the septum of the nose made for me by Dr.
Austin, showed many large dilated veins just beneath the
epithelium.

Case III. — Eecurring Epistaxis from the 10th year —
Multiple Telangiectases of slcin and mucous membranes of
nose and mouth.

M. W. C, Inez, Martin Co., Ky., aged 49, was admitted
to the Johns Hopkins Hospital, August 28, 1896, complain-
ing of epistaxis, which had recurred at short intervals from
his boyhood.

His mother died of consumption; she had had inflam-
matory rheumatism. His father died of Bright's disease.
He has three brothers and one sister living; one sister died
of consumption. So far as he knows there are no ' bleeders'
in his family, and none of the members have had serious
attacks of epistaxis.

AVith the exception of epistaxis, the patient has been a
healthy man. He had typhoid fever when twenty years of
age. He has never had rheumatism. He had gonorrhcea at
eighteen. He has never had syphilis. He has used alcohol
in moderation. He was a very active boy and took a great
deal of exercise. When tea years old he began to have
epistaxis, which often followed the trick of walking upon
his hands. He would bleed cjuite profusely for part of a
day, or for some hours every day or two for ten days or
more, until he got quite weak and anannic. The attacks
were sometimes of much greater severity than at others.
For some years he did not pass a week without bleeding from
the nose. It usually began as an oozing, and then would
end in a very free hsemorrhage, lasting from a few minutes
to half an hour. Between his eighteenth and twenty-fifth
years he was very much better, and it was thought that
perhaps the tendency had been checked. It did not stop
entirely, but he was very much better. Then it recurred,
and during all these years he does not think he has passed a
week without some bleeding from the nostrils, from either
one indifferently.

336

JOHNS HOPKINS HOSPITAL BULLETIN.

FNo. 128.

He has been an active business man, and the bleeding has
interfered very much with his work, as he would get pale
and very weak. He has often had to have the nostrils
plugged, and at times after severe bleeding he would get
very pale, and as he said, " the blood would be so watery
that my feet would swell." He never has had any hemor-
rhages into the skin, but he has had at intervals bleeding
from the ' spots ' on the gums and lips, he thinks perhaps as
often as twenty-five times. When a lad (he cannot fi.x the
exact date), he noticed reddish spots on his face and about
his hands; they have persisted and have increased in num-
ber during the past seven or eight years. He has never had
any other haemorrhages than those mentioned.

Present condition. — The patient was a very well nourished,
robust looking man, pale (as he had recently had a very
severe hfemorrhage), with all the outward evidences of anae-
mia. The blood count was: red corpuscles, 3,460,000; he-
moglobin 38 per cent. There was marked poikilocytosis; the
leucocytes were normal in number. The difEerential couut
gave lymphocytes 10 per cent, large transitional forms 9
per cent, polynuclear 80 per cent, eosinophiles 1 per cent.
The lymphatic glands were not enlarged. There were hte-
mic murmurs at the base of the heart, and a soft systolic at
the apex. Neither spleen nor liver was enlarged. The
coagulation time, as taken by Wright's tubes, was two minutes
and a half.

The telangiectases. — These were most numerous on the
face, which was much disfigured by them. On the right
cheek there were twenty-five, some of which projected
slightly beyond the skin as purplish spots from 1 to 4 mm.
in diameter; the largest presented a stellate arrangement of
veins. On the left cheek there were about twenty, several
with quite large veins passing to the centre. While most of
them were quite superficial, there were others subcutaneous
and bluish in tint. On the lower lip the edge at the skin
was closely set with them, and on the mucous membrane of
the left side there was an angioma the size of a split pea.
On the upper lip there were many small ones, and in the
very centre, just at the raphe, there was a large, deeply
seated, blue one. Scattered over the forehead were eight or
ten, most of them purplish red, one or two near the margin
of the scalp deep seated and blue. Here and there on the
scalp a few could be seen. On the upper surface of the
tongue there were five or six, and several on the under sur-
face, all of them small and very bright red in color. There
were none on the pharynx, but there were a number on the
inner surfaces of the cheeks and on the gums, which were
not swollen. The skin of the ears presented numerous pin
point telangiectases, giving to it a very peculiar appearance ;
the spots were about the size of the central point of a flea
bite.

Scattered over the back, chest and abdomen were two or
three dozen bright red angiomata, none of them more than
2 or 3 mm. in diameter. Several of them project, and one
or two are almost pedunculated. The aims and legs are
practically free, On the hands, however, there are a good

many angiomata, nearly all small and pin point. They are
scattered over the fingers and palms, i^articularly about the
pads of the fingers.

Dr. Warfield made several careful examinations of the
nose, and reported that on both sides of the septum there
were numerous scattered angiomata, very similar in appear-
ance to the smaller ones on the cheeks, and tortuous veins
coidd be seen radiating from their centres. With the ex-
ception of these spots the mucous membrane of the nose
and throat looked normal.

The patient remained in hospital until September 18th.
In the first ten days there were six bleedings from the nose.
On September 9th Dr. Warfield thoroughly cauterized the
angiomata on the septum. The operation was followed by
quite profuse hsemorrhage, which was readily stopped. On
the 10th the hcemorrhago recurred and he lost 580 cc. of
blood before it was checked by plugging. Half an hour
later he had a second ha?morrhage in which 820 cc. were
lost. Within twenty-four hours he bled 1400 cc. He was
not very much prostrated, but looked a little pale. This
was the largest bleeding he had had while in the hospital,
but he said he had not infrequently had much more profuse
ha?morrhage. Between the 10th and the 18th, the day of
his discharge, he had no bleeding.

Subsequent history. — Patient heard from June 5th, 1897.
He stated that he had been better than for any time for the
past ten years, biit he still has occasional bleeding for a day
or two jiretty freely. He thinks that the cauterization has
saved his life. He has been so much better since it was
done. After bleeding for a few days he takes the iron and
arsenic.

Oct. 11, 1897, I had a note from this patient to the effect
that he had had very severe bleedings during the past three
weeks.

Jan. 5, 1898. He has been bleeding very badly for the
past five weeks, and is in a very weak, critical condition.

Dec. 16, 1898, he writes, "I am still troubled with the
haemorrhages, but am able to attend business. I have pro-
cured in the last three months a gum arrangement, which I
insert and inflate with air, and keep it in for fifteen or
twenty-five minutes, and it stops the bleeding entirely. It
is a great improvement on the old plan of plugging with
cotton or anything else. I can use it at once myself, and it
causes no pain. Since I have had it I am holding my blood,
and I think now I will get stronger."

He sent a diagram of a very ingenious arrangement. Ho
took a rubber finger-stall about three inches long, into which
was tied a small bit of rubber-tubing, with a stop-cock at one
end. He inserted the finger-stall, relaxed, then put the
tubing in his mouth, inflated it, and turned the stop-cock.

Nov. 16, 1899. Patient heard from to-day. He says that
with the instrujnent above described he has succeeded in
"holding his blood." Still bleeds a little, but not so fre-
quently as he used to do. He has been able to attend to
business.

November, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

337

Eemarks.

Angiomata are very jDeciiliar and remarkable structures,
ill which I have been interested for many years. Apart
from the big uevi and angiomata with surgical relations tliere
are:

1. The pin-point, punctiforni, capillary angioma, of which
few skins lack examples. They may be numerous, but they
are rarely disfiguring. They appear and disappear. For
ten years I had one the size of a pin's head on a finger.

2. The solid, nodular nevus, ranging from 1 to 1 or 5 mm.
in diameter, forming a definite little tumor, either sessile or
pedunculated, and very common on the back.

3. The spider angioma, formed by (a) three or four dilated
veins, which converge to and join a central vessel; or (b)
which unite at a central bright red nodule projecting a little
beyond the skin. They are very common, and doctors are
often consulted about their presence on the face.

As examples may be found on the skin of nearly everybody,
these three varieties may be regarded as almost normal struc-
tures.

When the punctiforni or spider angiomata increase greatly
in numbers they are very disfiguring. In Case III the skin
of the face was peppered with them, and at a distance the
patient looked disfigured with a bright, fresh acne rash. In
Case I they had also proved a source of danger, as he had

bled from them repeatedly. An individual spider angioma
may increase in size, or, as in the cases I have here related,
they may become very numerous.

Angiomata have a curious relationship with affections of
the liver. In cirrhosis, in cancer, in chronic jaundice from
gallstones spider angiomata may appear on the face and
other parts. They may be of the ordinary stellate variety,
like the stars of Verheyen on the surface of the kidney, or
the entire area of the star may become diffusely vascularized,
so that there is a circular or ovoid territory of skin looking
pink or purple, owing to the small dilated venules. A dozen
or more of these may appear on the trunk, or even large
ones may disappear. And lastly, in a few cases of disease of
the liver I have seen large, mat-like telangiectases or angioma
involving an inch or two of skin, and looking like a very light
birth-mark, but which had appeared during the illness. The
skin was not uniformly occupied with the blood vessels, but
they were abundant enough on the deeper layers apparently
to give a deep cliange in color and to form very striking
objects. The dilated venules on the nose, and the ehaplet
of dilated veins along the attachment of the diaphragm are
not infrequently accompaniments of the spider angiomata in
cases of disease of the liver.

I have recently seen the spider angiomata appear in the
face in a case of catarrhal jaundice.

ON THE BEHAVIOR OF EPINEPHRIN TO FEHLING'S SOLUTION AND OTHER CHARACTER-
ISTICS OF THIS SUBSTANCE.

By John J. Abel, M. D.,
Professor of Pharmacology, Johns Hopkins University

It is a well established fact that epinephrin, the blood
pressure raising constituent of the suprarenal gland, is an
energetic reducing agent for such salts as silver nitrate, the
chlorides of gold and platinum, and potassium ferrocyanide,
but it has been proved entirely unable to reduce Fehling's
solution even on boiling. In my first paper ' on the active
principle of the suprarenal gland, especial attention was
given to this point. Tests with impure extracts of the gland
were not alone relied on, a benzoyl compound of epinephrin
was saponified by boiling its solution in glacial acetic acid
with an equal volume of 2-S't sulpliuric acid, and with the
products of this saponification all tests were made. The
results were negative, Fehling's solution was not reduced.
V. Fiirth ' later, also prepared and saponified this benzoyl
compound as well as an acetyl derivative of his own, and
he seems to have found nothing to conflict with his former
views, that the native ]irinciple does not reduce Fehling's
solution.

' Abel and Crawford, this Bullktin, July, 1897.
'Zeitschr. f. Physiol. Chem. Bd. xxvi, S. 15.

Fraenkel," Moore,' Metzger, " and v. Fiirth ' have also shown
that more or less purified extracts of the gland do not
reduce Fehling's solution, and I have failed to obtain this
reduction by the use of similar extracts, made in my earlier
experiments from sheeps', aud in my later, from beeves'
suprarenals.

The method employed by me in the preparation of these
extracts precludes the occurrence of cither reduction or
oxidation, except in so far as the latter might be induced by
exposure to air. The glands were digested in some instances
with pepsin, in others with papoid ferment, and only methods
of solution and precipitation with organic fluids, such as
alcohol, acetone, toluol and ctlicr were employed.

In the case of tliese extracts, the failure to reduce Fehling's
solution might possibly be attributed to sonie disturbing

3 Wiener med. Bl.itter, 1890, No. 20, p. 400.
<Journ. of Physiol., vol. 17, Proc. Physiol. Soe., p. xiv.
5Zur Kenntnlss der wirksamen Substanzon der Netjennieren, Diss.
Wurzburg, 1897.
sZeitschr. f. Physiol. Chem., Bd. xxiv, S. 143.

338

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

substance which interferes with the reaction. In the ease
of the benzoyl componnd, it might be charged that the active
principle was oxidized, either in the process of benzoating or
in the subsequent saponification, and that it was, perhaps,
originally able to reduce Fehling's solution. This appears
less probable when it is remembered that the active prin-
ciple is still able to reduce silver nitrate and other salts after
its liberation from its benzoyl compound by the method
just cited.

The iron compound of v. Fiirth also does not reduce Feh-
ling's solution. Here again it might be asserted that the
power to do so was lost by oxidation in the preparation of
this iron salt, but this assumption, like the above, is without
experimental foundation, for the reason that the properties
of the substance as contained in this iron compound, remain
unchanged in all other respects. The possibility of an oxi-
dation in the preparation of this compound is not denied.
There is, however, no reason to assume that its occurrence
would abolish the power to reduce copper sulphate and not
affect its behavior towards other salts.

Lastly, as will presently be shown, an apparently pure sul-
phate or bisulphate obtained from a basic lead precipitate of
aqueous extracts which have been made by extraction of
the glands with very dilute sulphuric acid and zinc dust,
also fails to reduce Fehling's solution on boiling. There
appears to be no ground for the assumption that oxidation
took place in the course of the precipitation with basic lead
acetate.

Existing evidence, therefore, points to the conclusion that
epinephrin in its active, unaltered state is not capable of
reducing Fehling's solution.

It will now be demonstrated that this additional property
can easily be conferred upon this substance without clianging
its behavior to other metallic compounds. It is then, how-
ever, modified in several of its physical characteristics. Its
solutions, for example, are not quite so rapidly oxidized on
exposure to the air, and the free reduced base, as prepared
by Takamine and Aldrich, is non-hygroscopic and capable
of crystallization. This point, therefore, is of importance
in the elaboration of methods for isolating this principle.
The salts of this modified form of our substance are, however,
as hygroscopic and difficult to crystallize, as are those of the
unaltered substance.

This change of native epinephrin to the copper sulphate
reducing form, is best effected by means of sulphuretted
hydrogen, as illustrated in the following experiment.

After decomposition of v. Fiirth's lead precipitate of im-
pure epinephrin (suprarennin) in the manner described by
that author, and after repeated solution in methyl alcohol
of the sulphates thus obtained, and repeated fractional pre-
cipitation with ether, there is finally obtained a hygroscopic,
amorphous sulphate or bisulphate of native or unaltered
epinephrin which possesses a high degree of purity. This
salt is amorphous when finally washed with ether and dried,
but in the final precipitations with ether, it is thrown out
of its methyl alcohol solution in what appears to be a

minutely crystalline condition. The little particles that set-
tle on the sides of the flask look like crystals when viewed
through the ethereal fluid with a pocket lens. However, in
the subsequent washings with ether the salt absorbs water
on account of its hygroscopic qualities, and in consequence
the crystals take on an amorplious character.

This metliod yields a salt of at least as high a degree of
purity as adrenalin, as is proved by its physiological activity
and by colorimetric comparisons witli adrenalin, in which
the latter is dissolved in an amount of sulphuric acid esti-
mated to be equivalent to that contained in the sulphate.
In these comparisons the fine green tint developed by dilute
ferric chloride was employed as a means of comparison and
no difference could be detected between the two. The proof
of its high physiological activity was furnished in the ex-
periments made with it by Prof. Reid Hunt, and published
by him in the American Journal of Physiology for March,
1901. No investigator has thus far worked with a more
active specimen of the blood pressure raising constituent, as
will be seen by a comparison of Hunt's data with any others
published. It will, I tliink, be admitted that this salt was
sufficiently pure to furnish conclusive evidence that un-
altered epinephrin cannot reduce Fehling's solution.

By the following method its character in this regard can
be entirely changed. If hydrogen sulphide be passed
through an aqueous solution of the salt it soon becomes
turbid in consequence of the liberation of sulphur. In case
the solution has been thoroughly charged with the gas,
if it is cooled and set aside for a few hours, the deposition
of sulphur appears to increase. If then filtered, repeatedly
shaken with chloroform and concentrated in vacuo until all
traces of hydrogen sulphide and chloroform have disap-
peared, it promptly reduces Fehling's solution on boiling.
All methods of isolation, therefore, that involve the use of
hydrogen sulphide or of alkali sulphides will yield a modi-
fied or reduced form of the active principle, provided, in the
case of hydrogen sulphide, the gas is passed into a solution
whose reaction is only slightly acid. The adrenalin of Taka-
mine is such a reduced form, as it is also easily oxidized by
Fehling's solution, a fact which seems to have escaped the
notice of Takamine and also of Aldrich, who has lately
prepared adrenalin by a method which involves the use of
hydrogen sulphide.

Other methods of reduction also effect the change just
described. Thus: a purified extract of the gland, which con-
sists largely of native epinephrin is dissolved in alcohol con-
taining hydrochloric acid, and is then reduced by boiling
with granulated tin and strips of platinum for six hours or
more. After cooling, the solution is filtered and the filtrate
precipitated with alcoholic solution of ammonia. In this
way a small yield of a tin compound of reduced epinephrin
is obtained. On being washed and dried, the compound pre-
sents the appearance of a white powder, not very solulile in
water but intensely active in a physiological way. It re-
duces Fehling's solution on boiling for a minute or two. If
the compound be boiled in water with zinc dust, thus replac-

NOVEMBEE, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

339

ing the tin with zinc, the resnlting compound also reduces
Fehling's solution.

If the tin is removed by means of hydrogen sulphide in
the presence of a dilute acid a hygroscopic salt may be pre-
pared which also reduces alkaline copper salts.

This unstable substance is also capable of self-reductioa.
It has just been stated that when its benzoyl compound is
saponified in a mixture of glacial acetic and 25^ sulphuric
acid, the change into the copper sulphate reducing modifi-
cation does not occur.

Wlien, however, either the benzoyl or acetyl compound is
saponified in the autoclave, with water alone or with a l'j(
solution of sulphuric acid, and under a pressure of two or
three atmospheres, this alteration is brought about. That
this fact was not mentioned in my earlier papers is accounted
for by a neglect to apply Fehling's test when the methods of
saponification were changed. My earlier work, and also that
of others, had shown that when epinephrin is boiled with
mineral acids in open vessels or in sealed tubes, no reducing
substance is obtained, and it was only later, after I had
found how the substance is altered by hydrogen sulphide,
that I again applied the test to my series of autoclave pro-
ducts.

The reduced product, as obtained by the use of the auto-
clave differs, however, in a few particulars from that ob-
tained by the use of hydrogen sulphide and other chemicals.
The former product appears to be even more easily oxidized;
it is certainly more sensitive to the action of alkalies and to
exposure to the air. Furthermore, the addition of very
dilute ammonia nearly to the point of neutralization causes
the reduced product from the autoclave to fall out of even
a dilute solution in the form of white flocks, which rapidly
assume a reddish brown and finally a dark brown color.
When this flocculent precipitate is washed with alcohol and
ether, and dried, it is found to have lost its physiological
activity. It is also precipitated by a number of alkaloidal
reagents, a point to which I have called attention in a
previous paper.' From some of these differences it might
be concluded that the autoclave product is further reduced
than that treated with hydrogen sulphide. Analyses and quan-
titative tests with alkaline copper solutions must settle this
point. Wlien a dilute solution of the reduced commercial
compound called adrenalin, which fails to give a precipitate
with ammonia, is slightly acidulated with sulphuric acid, and
then treated in the autoclave under a low pressure as in the
saponification experiments above described, no black resin
or oxidation product is thrown out, but the solution, while
retaining its reducing power for alkaline copper salts has
developed the additional characteristics just alluded to.

A suggestion as to the action of hydrogen sulphide and
of reducing salts and also in respect to the similar effect
produced in the autoclave, is now in order.

It would be strictly in agreement with chemical experience

'This Bulletin, March, 1901.

if we were to assume that the agents named cause this Tin-
stable substance, which already possesses the power to reduce
many metallic compounds, to take up more hydrogen.

The analogoiis change produced in the autoclave, must
evidently be classed with other examples of self-reduction.
I have elsewhere stated that a considerable loss of material
occurs when this apparatus is employed, as a large part of
the epinephrin is deposited in the form of an insoluble and
resinous oxidation product. It is apparent, then, that oxida-
tion and reduction go on simultaneously in the autoclave.

AVhether the mechanism of the reduction is alike in all the
instances cited above, and whether it consists in the assump-
tion of hydrogen or in the loss of oxygen, must finally be
decided by analysis.

ON THE EETENTION OF A BENZOYL RADICLE IN

MY FOEMER SERIES OF EPINEPHRIN

COMPOUNDS.

Attention may now be called to another point in which
the autoclave is concerned. I have repeatedly stated that
my whole series of epinephrin compounds was derived from
an original benzoyl compound, the form in which epinephrin
was isolated from the gland, and that this compound, which
is entirely insoluble in water, was saponified in the autoclave.
My analyses forced me to assign the formula Ci-Hj^NO^ to
the active principle, both in its physiologically active and in
its inactive modifications.

Later work has shown me that my whole series of deriva-
tives contains an unsaponified benzoyl radicle. That this
benzoyl group escaped the fate of its fellows could not be
known with certainty until epinephrin should be isolated by
other methods. I early became aware of the fact that when
the epinephrin bisulphate of my early papers is subjected to
destructive treatment, such as heating in a sealed tube at
150° C, with 25<^ hydrochloric acid, an ether-soluble acid,
which in every way resembles benzoic acid, is split off' from
it. I stated this to be the case in a paper published in the
Zeitschrift fiir Physiologische Chemie, Vol. XXVIII, p. 348,
and I will here add that the melting point of this acid, after
only once subliming it from the ether residue was 120° C.

In repeating this work I have found that it is only neces-
sary to treat inactive epinephrin, the highly active bisulphate
of my former papers, in a test tube with nearly concentrated
sulphuric acid, heating gently over a free flame, then diluting
with water and extracting with ether, to secure benzoic acid
in abundance. The iron compound of v. Fiirth, which is a
derivative of native epinephrin, as also the reduced com-
pound called adrenalin, yield nothing whatever when treated
in the manner described. Instead of finding the bowl from
which the ether is evaporated lined with crystallized benzoic
acid, one finds in the case of these compounds merely a trace
of an amorphous fatty substance. I have not thought it
necessary to make a quantitative estimation of the benzoic
acid that is thus split off from epinephrin, since a preliminary
analysis of adrenalin and also of the acetyl derivative of v.

340

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

Fiirth's ferri-suprarennin had shown me that a single ben-
zoyl radicle accounts fully for the quantitative differences
in the composition of these seTeral modifications of what
is one and the same substance.

In order to arrive at the true formula for reduced epine-
phrin we must therefore subtract from Cj^HigNO^ the re-
tained benzoyl group (CsHjCO), and restore the hydrogen
atom that was displaced by the radicle. This will give us
CioHiiNOj as the empirical formula for reduced epinephrin.
In accordance with this cliange in terminology, CuHi^NO^ ,
the form in which this principle was first isolated by me,
and which yields stable and non-hygroscopic salts, should
now be called mono-benzoyl reduced epinephrin. The term
reduced, as already stated, applies to the product as altered
by hydrogen sulphide and other reducing agents. The
native substance, very soluble, apparently very hygroscopic,
less stable and non-copper-reducing should be called native
or unreduced epinephrin. This variety of the substance has
been isolated by me as the hygroscopic sulphate or bisul-
phate which was employed in the experiments with hydrogen
sulphide previously described.

COMPARISON OF EPINEPHRIN WITH THE SUB-
STANCES KNOWN AS SUPRARENNIN
AND ADRENALIN.

Coutemporaneously. with my paper published in this Bul-
letin for Sept.-Oct., 1898, in which I showed that the blood-
pressure-raising substance as isolated by my methods is rep-
resented by the empirical formula Ci-H^jNO^ and in which
I had proposed the name epinephrin for this substance, ap-
peared a paper by 0. v. Fiirth,' who declared the substance
in question to be either tetraliydrodioxypridin, CsH^NO,,
or diliydrodioxypyridin, CjH-NO, . In a later paper " con-
taining no further analytical data, the author describes the
isolation and preparation of a new iron compound and pro-
poses the name suprarennin for our substance. In it he
makes the erroneous statement that epinephrin is something
entirely different from the true blood-pressure-raising prin-
ciple and that its resemblances to this principle are due
solely to a slight contamination with it, a mistake into which
he was evidently led by a very imperfect and faulty repeti-
tion of some of my work, the neglect to consider that this
highly sensitive and unstable substance developes new
characteristics with each change of method, and also by the
very important omission to analyze either his iron compound
or its derivatives.

I need only point to a recent paper'" in reply to v. Fiirth.
to the analysis of the acetyl derivative of his iron compound
which will presently be given and to Aldrich's analysis of
the adrenalin of Takamine to show how entirely without
foundation is v. Fiirth's assertion that either C,,k,NO, or
C^HjNOj represents the composition of epinephrin, or, of

«Zeitschr. f. Physiol. Chem. Bd. xxvi, S. 15.
'Ibid. Bd. xxix, S. 105.
'"This Bulletin, March, 1901.

what he calls suprarennin. This inadequate formula was de-
rived by him from the analysis of an acetyl derivative which
was made directly from a highly impure extract containing
other substances equally capable of being acetylated and it
was not fortified by analyses of derivatives.

From all that has been said here and in an earlier paper it
will be seen that suprarennin is nothing else than epine-
phrin, that is, it is equivalent to a non-reduced form of this
substance, freed from the included benzoyl group.

It is possible that in the formation of v. Fiirth's ferri-
suprarennin, the only derivative even approximately pure
that he has thus far prepared, an oxidation of the native
principle occurs. On this assumption his suprarennin would
not represent the native or non-reduced form of the sub-
stance, but rather an oxycompound. As pointing to this
conclusion the following experiment may here be cited.
More than a year ago, I prepared an acetyl derivative from
ferri-suprarennin. Since it is difficult to purify this iron
compound, its acetyl derivative was saponified in the auto-
clave, the liberated suprarennin was transferred into a
picrate by extraction with acetic ether after the previous
addition of a solution of picric acid, and the picrate thus
obtained M-as transferred into a sulphate by the methods de-
scribed in previous papers. This sulphate was now acet}'-
latcd and the resulting amorphous, dark colored compound
dried over sulphuric acid in vacuo and analysed. The follow-
ing percentages of carbon, hydrogen and nitrogen were ob-
tained:

Required for CioHgNO/CHjCO),

C = 57.31
11= 5.07

Found.

C = 57.51
H= 5.05

N= 4.37
N= 4.18

4.18

The two nitrogen analyses were made by the method of
Kjeldahl. A duplicate analysis for carbon and hydrogen
made from a specimen dried at 110° gave somewhat higher
percentages than the above, and is not here given, as de-
composition had imdoubtedly taken place. The assumption
that this product contains three and not four acetyl groups,
is in line with v. Fiirth's contention that the native sub-
stance takes up three acid radicles.

On this assumption, the above analysis would lead to the
rational formula CioHnNO^, instead of CjoHjiNOg. The
additional atom of oxygen may have been taken up either
in the course of the formation of the original iron com-
pound, or in the process of acetylating it. Although unable
to decide this point, I have presented the above analytical
data to show how exact an approximation to my formula may
be obtained in the case of a derivative which is made from
so called suprarennin.

It is freely admitted that my empirical formula may, in
the future, when a more perfect series of compounds shall
have been made, prove slightly incorrect. Even then the
fact will remain that the isolation of epinephrin was first
effected by my methods, admittedly capable of improvement
as these are.

NOYEMBEE, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

341

The more recent work of Takamine and of Aldrich may
now be considered.

The former " has the credit of having devised a method by
which the free reduced and physiologically active base may
be manufactured on a commercial scale and this modification
of epinephrin has been named adrenalin. Its reducing
power for copper sulphate, its relatively greater stability, its
very slight solubility in water and its non-hygroscopic and
crystalline condition are among the characteristics that dis-
tinguish it from the native principle as it exists in the gland.
Crystalline salts, which are non-hygroscopic and maintain
their form on exposure to air have not yet been made from it.

Adrenalin agrees with my earlier compounds, notably
with the picrate and bisulphate, in all of the properties
alluded to, with the exception of its more ready and perma-
nent crystallization. In an earlier paper statements will bo
found regarding the extent to which some of my salts were
crystalline, and I may here add that in the course of prepa-
ration of a picrate of my phenyl di-carbamic ester of mono-
benzoyl reduced epinephrin, this salt fell out of a hot, weak,
alcoholic solution in the form of large, broad and very thin
crystalline plates. On attempting to recrystallize it, how-
ever, it fell out in the form of small spherical nodules.
Since this time I have had no occasion to repeat the work.

Takamine has thus far failed to describe his methods or
to give any analytic data as to the elementary composition
of adrenalin. Such an important characteristic as its power
to reduce copper sulphate, a property not possessed by the
native principle, if known to him was for some reason not
stated.

Aldrich, in a recent paper," though like others, unaware
of Takamine's method, states that he has isolated the adre-
nalin of this chemist by a method whose essential points are
the use of lead acetate for the removal of inert substances,
as originally advised by Holm," and later by v. Fiirth," and
of ammonia for the precipitation of the free base as originally
used by me in the case of reduced mono-benzoyl epinephrin.
An important step in this method, of whose significance
Aldrich appears to be unaware, is the use of sulphuretted
hydrogen for the removal of excess of lead. As already
shown, this must effect a reduction, and inasmuch as Aldrich
declares his adrenalin to be identical with that of Takamine,
it is safe to assume that the acidity of his solutions was not
high enough to prevent the occurrence of this reaction.

Both Takamine and Aldrich appear to believe that adre-
nalin is a pure compound, a true chemical individual. The
former has said,'' " I am now pleased to announce that I
have succeeded in isolating the blood-pressure raising prin-
ciple in a stable and pure crystalline form;" and the latter
has stated " that he has ol)tained the compound " in distinctly

" Therapeutic Gazette, vol. xxv, p. 231.

15 American Journ. of Physiol, vol v, p. 4.57.

isjonrn. f. pract. Chem. Bd. 100, (1867), S. 150.

'< Zeitsehr. f. Physiol. Chem. Bd. xxix, (1900), S. lO.').

I'Loc. cit. p. 223.

l6Loc. cit. p. 458.

crystalline and jDure condition; " but in a later section of
his paper in which he comments on the close approximation
of his formula to that now given for epinephrin, he is less
emphatic and gives expression to a doubt by saying" "that
the difference can be readily explained if we suppose either
of the substances to be contaminated with other bodies." The
arithmetical mean of the concordant analytical numbers
given by Aldrich, shows that the elementary composition of
Takamine's adrenalin is represented by:

C = 58.03
H= 7.20

N= 7.GG
0 = 27.11

and by

C = 57.89
H= 7.33*

]Sr= 7.50
0 = 27.27

100.00

99.99

*A misprint occurs in the table as given by Aldrich. The value for
hydrogen should be given as above and not 7.23 as given in his paper.

for the identical substance as isolated by himself.

Using these analytical data for the determination of an
empirical formula, Aldrich finds that "the simplest body
obtainable is represented by the formula CoHisNOg."

The calculated values for the formula are, however, not
placed by the side of the above data for comparison. When
these values are calculated, taking 0 = 16 and whole num-
bers for H and N as Aldrich has done in calculating his
analytical results, the following is the result:

Theoretical for CoHuNOj.
C= ["59l)2"|
H= 7.10 , 1

]Sr= 7.65
0 = 26.23

100.00

On comparing these theoretical values with those actually
obtained by Aldrich, it will be seen at once that the assumed
formula does not coincide with the analytical data. In the
case of Takamine's adrenalin the mean percentage of carbon
as found by Aldrich falls 1^ below that required by the
formula and in the case of his own compound it falls 1.13^,
in the case of one of the two analyses even 1.38^, below the
requirements of the formula. This very great deficiency in
carbon is the more striking when it is observed how close is
the approximation of the obtained hydrogen to that required
by theory.

Furthermore, the nitrogen of the compound is estimated
by the method of Dumas and the percentage as found is, in
the case of Takamine's substance, in exact agreement and in
the case of Aldrich's compound falls slightly below the theo-
retical requirement. Exact agreement with the theoretical
requirements is unusual in the employment of this method
even when very special precautions are observed, of which

"Loc. cit. p. 461.

342

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

there is no evidence in this case, while an analytical defi-
ciency in nitrogen is in direct opposition to the results of
experience with this method, so that both considerations
strengthen the conviction that a true formula calls for less
nitrogen than does the one proposed by Aldrich.

The great deficiency in carbon that has been pointed out
would in itself condemn the assumed formula.

It must be remembered that Takamine and Aldrich are
dealing with a substance which they say " was obtained in a
distinctly crystalline and pure condition," and they must,
therefore, meet the standards universally adopted by chem-
ists for a substance of that character. It is moreover agreed
that a strict adherence to these standai'ds is especially neces-
sary in determining an empirical formula based on the an-
alysis of one compound only and unfortified by an analysis
of derivatives. In the case of a series of compounds such a
deviation from the theoretical requirement may occur in one
instance or another of the -°^ries as a consequence of drying
at too high a temperature or for some reason unexplainable at
the time, and under such circumstances the analysis may be
allowed to pass.

Not only is the assumed formula inadequate but the case
is such that it is impossible to calculate a rational formula
that will agree with the analyses given. In other words,
adrenalin as analysed by Aldrich is proved by his own data
to be a mixture and not an individual substance.

Several possibilities suggest themselves in explanation of
this failure to calculate a formula; adrenalin may be simply
a mixture of reduced and non-reduced epinephrin; or, it may
consist of reduced epinephrin contaminated with ammonium
acetate (whose presence is accounted for by the method em-
ployed), or it may be contaminated with some one of the
numerous nitrogenous bases with which the gland abounds.
On any one of these suppositions, the analyses would show
a lower percentage of carbon and a higher percentage of
nitrogen than is required by the formula for reduced epine-
phrin, CjoHiiNOa.

I conclude that the first suggestion is the most probable
for the reason that adrenalin possesses a very high degree of
physiological activity, as shown by experiments with it in
my laboratory, that it has a tinctorial power when treated
with ferric chloride practically equal to that of native salts
prepared by other methods, and also because it reduces
copper sulphate. On this last point, which would give de-
cisive information, no quantitative experiments have been
made.

At the time when the colorimetric comparisons here al-
luded to were made, I had not as yet perfected the method
which will presently be described, and I would not have it
assumed that there was no chance for error in these estima-
tions or that blood-pressure tests are anything more than a
guarantee of an approximate degree of purity. In estimat-
ing the value of the several suggestions above made to ac-
count for Aldrich's inability to assign a correct rational for-
mula, it must be borne in mind that a substance which falls
out of solution as a finely divided, microcrystalline powder

is very apt to carry down foreign substances and to hold
them with tenacity.

It must be apparent that both suprarennin and adrenalin
are nothing but modifications of the substance tiiat I have
called epinephrin. All these substances behave in the same
manner toward solutions of silver nitrate and other oxidizing
salts, all alike form iron and other metallic derivatives, all are
equally capable of being acetylated, beuzoated, etc.; all can
be made to show the characteristic autoclave effect, all yield
with alkalis, a peculiar basic substance of a coniine-piperi-
dine-like odor and a black pigment of acid character, and
have many other characteristics in common.

The formula assumed for suprarennin has been shown to
be entirely inadequate, and I entertain the hope that a
better purification of adrenalin (C9H13NO3), and an analysis
of its derivatives will result in a closer approximation to my
formula, CjoHiiNOa. In order to give additional grounds
for this formula I may here present the results of an analysis
of a sulphate of the phenyl carbamic di-ester of reduced
mono-benzoyl epinephrin. This compound, which had passed
through five previous chemical stages, a fact which gives
additional guarantees of individuality, was briefly described
in the American Journal of Physiology, March, 1900 (Proc.
Amer. Physiol. Soc, p. xvii). Although only one analysis
was made, the results are given on the assumption that they
are of value even without duplicates, inasmuch as they coin-
cide fairly well with those obtained for the whole series.

Found. Calculated lor [C„U,3NOi2(CO.NH.C6H6!]jH,S(),

C== 63.14 C = G3.70

H= 4.89 H= 4.45

H2S04= 8.46 H,SO^= 8.39

As the material used in the preparation of this ester was
tlie bi-sulphate of mono-benzoyl reduced epinephrin (Ci^Hu
NO4) calculation easily leads to CioHnNOa as the formula
for the free reduced base.

OUTLINE OF A METHOD FOE THE QUANTITATIVE

ESTIMATION OF EPINEPHEIN BY COLOEI-

METRIC COMPAEISONS.

It has been known since Vulpian's time that aqueous or
dilute alcoholic extracts of the suprarenal gland give a pure
emerald green color with ferric chloride. When this test is
made with pure epinephrin or with one of its salts, it is found
that the color persists for a very brief period only, rapidly
giving place to a pink and later to a dark brown shade.

The fleeting nature of this color reaction has made it im-
possible hitherto to base a quantitative method of estimation
upon it. I have now made the observation that the addition
of an equal quantity, or, better, of an excess of potassium
benzene thio-sulphonate to a solution containing epinephrin,
results in a very prolonged fixation of the green color pro-
duced by ferric chloride. Solutions thus treated have main-
tained their tint unaltered even after an exposure of several
days to the air of the laboratory.

November, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

343

This salt similarly fixes the green color produced in solu-
tions of pyrocatechin by the addition of ferric chloride, and
the reaction probably applies also to related compounds. An
alcoholic ether solution of pyrocatechin which contained
enough water to hold the added thio-sulphonate in solution,
maintained the green color conferred upon it hy ferric chlo-
ride, in all its intensity after standing in my laboratory for
four months.

It may he remarked in this connection, that it now becomes
jiossible to isolate and study this ferric compound of pyro-
catechin.

It will readily be seen that a quantitative colorimetric
method for the estimation of epinephrin, pyrocatechin and
other compounds may be based on the peculiar stability
wliich is conferred upon their ferric compounds by potassium
benzene thio-sulphonate. I have not yet had time to elaborate
the details of the method, or to determine the range of its
applicability, and I shall not here enter upon an explanation
of the chemical reaction involved.

SUMMARY.

The following conclusions, drawn from the present paper,
are here given, together with a few points whose tenability
is easily established by a perusal of my former papers.

1. Epinephrin in its native state easily reduces silver ni-
trate and other metallic salts, but fails to reduce Pehling's
solution. On being treated with hydrogen sulphide or with
hydrochloric acid and tin in the proper medium, or on saponi-
fication of its benzoyl or acetyl derivatives in the autoclave, it
becomes an energetic reducing agent for alkaline copper so-
lution and causes an abundant precipitation of cuprous
oxide in the boiling mixture. This change in respect to cop-
per sulphate is accompanied by an alteration in other pro-
perties. The substance is now not quite so easily oxidized on
the addition of dilute ammonia, and is more easily crystal-
lized.

8. The commercial preparation known as adrenalin also re-
duces copper sulphate. It is apparent from the analytical
data furnished by Aldrich that this substance is a mixture
and not a chemical individual. The proposed formula

CgHiaNOs , does not coincide with the analytic data furnished
by Aldrich, and no rational formula is deducible from them.
Adrenalin is very probably chiefly a mixture of native and
reduced epinephrin, containing traces of foreign substances
rich in nitrogen. It is hoped that a better purification to-
gether with an analysis of its derivatives, will result in a
closer approximation to the formula CioHuNOj, which ap-
plies to reduced epinephrin as contained in my series.

3. The series of epinephrin compounds described by the
writer in previous papers, have one and all retained a single
benzoyl radicle, in consequence of the incomplete saponifi-
cation of the original benzoyl derivative. This could not be
determined with certainty until the substance was isolated
by methods which avoided the process of benzoating. The
epinephrin, CijIIisNO^, of my former papers was therefore
in reality mono-benzoyl epinephrin, and in consequence of
its ability to reduce alkaline copper sulphate it may further
be designated, reduced mono-bcTizoyl epinephrin.
, 4. Elimination of the retained benzoyl radicle (C5II5CO),
and substitution of the displaced hydrogen atom leads to the
formula CioHnNOj, as an adequate empirical expression for
reduced epinephrin, at least for epinephrin as reduced by
saponification in the autoclave.

5. My own work, as also that of Aldrich, shows that the
statement of v. Fiirth that the substance under discussion is
either tetrahydrodioxypyridin C^HoNOo , or dihydrodioxypy-
ridin C5H.NO2 , is no longer tenable.

6. Reduced epinephrin is capable of taking up four acid
radicles. This is shown in an earlier paper in which it was
demonstrated that mono-benzoyl epinephrin is capable of tak-
ing up three acetyl groups. Mono-benzoyl epinephrin is also
capable of forming a phenyl carbamic di-ester, and probably
even a tri-ester on more vigorous treatment with phenyliso-
cyanate (CO.N.C„H,).

7. Potassium benzene thio-sulphonate, KS.SOoCsHj , added
to a solution of epinephrin fixes the emerald green color which
appears on the subsequent addition of ferric chloride. A
colorimetric quantitative method may be based on this re-
action. The ferric compound of pyrocatechin is also per-
manently fixed in its tint by this sulphonate, and the reac-
tion possibly applies to related compounds.

OSTEITIS DEFORMANS WITH REPORT OF A CASE.*

By Arthur W. Elting, M. D.,

Attending Surgeon, The Child's Hospital.

[Chief of the Surgical Clinic^ The Albany Ilofipiial)^

Albany, New York.

To Sir James Paget belongs the credit of having described
in a clear and concise manner an unusual form of disease

* Read before the Medical Society of tbe County of Albany, Nov. 13th
1900.

characterized by hypertrophy and deformity of certain of
the bones of the skeleton. To this disease he gave the name
of osteitis deformans.

Paget's' original communication was presented to the med-

344

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

ical and chirurgieal society of London in 1876 and included
a report of five cases observed by himself. Certain cases re-
ported in earlier times as partial or local osteomalacia were
imdoubtedly cases of osteitis deformans, as, for instance,
cases reported by Saucerotte'' in 1801, Enllier' in 1812,
Seontetten* in 1841, Wrany" in 18G7, and Mosetig" and
Wilks ' in 1868. Certain of these cases Paget himself recog-
nized from the description given as being in all probability
osteitis defonnans.

Czerny' in 1873 first introduced the term " osteitis
deformans" in connection with a case of gi-adual spon-
taneous development of a curvature of the lower legs. Benno
Schmidt," in 1874, used the term in connection with a
ease of spontaneous development of curvatures of the
tibia and femur, and Volkmann,'" in 1874, used the term in a
similar case in wliich the curvature was confined to the tibia.
The points of differentiation from osteomalacia emphasized
by these observers were the inflammatory symptoms mani-
fested by the involved bones and especially the pain.

The term " osteitis deformans " was thus not a new one,
but it was Paget who first applied it to the peculiar disease
entity which he described. Since Paget's original commu-
nication a considerable number of characteristic eases have
been reported. Up to 1890 Paget himself had seen 23 cases,
far more than has fallen to the lot of any one else to observe.

More cases of osteitis deformans have been reported from
Great Britain than any other country, but this is probably due
to the fact that the interest aroused by Paget in the subject
has led to a more careful search for such cases. The next
greatest number of cases of osteitis deformans have been
reported from France, where the work of Eiehard," Thi-
bierge," Joncheray," and others has aroused especial interest
in the condition. A few cases have been reported from Ger-
many, Austria and Italy. So far there appear to have been
seven eases of osteitis deformans reported from America.
The first case was that of MacPhedran," of Toronto, reported
in 188.5. The second was reported by Gibney," of New
York, in 1890. The third by Mackensie," of Toronto, in

1891. The fourth and fifth by Taylor," of New York, in

1892. The sixth by Herwisch. of Philadelphia, in 1896, and
the seventh by Watson," of Baltimore, in 1898. Watson's
case was more characteristic than any of the former ones
reported from this country.

Many of the cases reported have been accompanied by
pathological reports, the most valuable contributions having
been made by von Eecklinghausen," Stilling,'" Paget and
Butlin." von Eecklinghausen called the disease osteomye-
litis fibrosa and demonstrated its identity with certain eases
of local osteomalacia of earlier writers.

The involvement of the different parts of the skeleton
varies in difEerent cases. All of the long bones, the clavicles,
the flat and short bones, and especially the vertebra;, may be
more or less affected. The tibia appears to come first in the
order of frequency of involvement and in some cases is the
only bone involved. Next in order of frequency comes the
skull which is also in certain cases alone involved, and the

vertex is more commonly affected than the base. The femur
appears to come next while the frequency of involvement of
the other bones of the skeleton varies greatly. The disease
rarely attacks the bones of the face, although cases are re-
ported in which the superior and inferior maxilla as well as
the zygoma have been affected.

Based upon Butlin's microscopical studies of the first case,
Paget laid the chief emphasis upon the inflammatory absorp-
tion of the bone associated with the formation of lacunae.
He believed the fibrous character of the bone marrow to be
the result of the long duration of the inflammatory process.
He also called especial attention to the apparently increased
vascularity of the affected bones as evidenced by tlie enlarged
blood-vessels of the periosteum and bone. Many other ob-
servers do not share the views advanced by Paget and Butlin
as to the inflammatory character of the disease. Stilling, in
his report of three carefully studied cases, discusses the
pathological process and states that the disease begins beneath
the periosteum and gradually involves the more central por-
tions of the bone. There is at first an absorption of the bone
with the formation of Howship's lacunae, Haversian spaces
and perforating canals. In these changes Stilling believes the
process resembles that which occurs in oidinary rarifying
osteitis. In addition to the absorption, however, as in all
chronic inflammations of bone, there is a new formation of
bone, partly in the marrow and partly beneath the peri-
osteimi. Stilling states that both processes appear to go on
at the same time and that the newly-formed bone may again
be absorbed. The absorption appears to gradually grow less
while the new formation continues, and thus the bones come
to present most marked modifications, both of the internal
structure and external appearance. They become thick and
misshapen.

The new-formed bone remains for a long time uncalcified,
and is, therefore, soft and has a tendency to yield under the
body weight. Sometimes, however, there may be more or
less calcification of the new-formed bone, as evidenced by
calcified areas demonstrated here and there.

The tibia and femur become bent anteriorly or laterally or
both; the angle of the neck of the femur to the shaft is
changed; the vertebral column presents abnormal curvatures
and the lower part of the skull is pressed upward toward the
cranial cavity.

Lancereaux '' believes tlie pathological process to be char-
acterized by an absorption of bone followed by a process of
bone formation, and that the latter is merely a reparatory
process.

Against the view that the bone formation in osteitis de-
formans is merely a regenerative process, Silcock'" and von
Eecklingliausen have urged that the new formation does not
occur upon the side of the concavity, and furthermore that
the thickening of the bone can be demonstrated at the very
beginning of the disease. Mere quantitative variations in
the absorption and formation of bone in osteitis deformans
do not explain the condition, but the quality of the bone
formation must also be considered.

NOVEMBEE, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

345

According to von Eecklinghausen's investigations, the
changes occur in the following manner: At first there is a
simple osteomalacia with a marked reduction of the cortical
substance of the bone, as a result of which the bones become
bent. Following this an inflammatory process develops in the
malactic areas which is characterized by the transformation
of the fatty and lymphoid marrow into fibrous tissue, from
which a compact network of bone develops which contains
much fibrous tissue, and which remains uncalcified for a long
time. Where the disease has existed longest this process may
load to a complete disappearance of all the old bone tissue.
From this result the great modifications of the bony structure.

The fact that the anatomical findings of all the writers do
not agree is probably because the cases have been studied at
different stages of the disease. In cases in which the progress
of the disease is a slow one, as in Paget's first case, as well
as in the cases of so-called local osteo-malacia of early writers,
the most characteristic feature is the presence of a finely
porous bone tissue situated in the cortex of the long bones
and occasionally in the medulla, as well as in the spongy
tissue of the short and flat bones. These areas in some places
present little or no calcification, while in other places there
is a marked deposition of calcium salts, and at times one may
encounter areas of an ivory hardness which might be con-
sidered as evidence of a healing process.

In the more advanced stages of the disease the bone marrow
presents the appearance of a pale or reddened fatty marrow.
In cases developing rapidly, especially those in which there
is a general distribution of the process over the skeleton, the
new bone and the fibrous bone marrow are much in evidence.
The porous bony tissue may be found to have replaced the
compact cortex or to have developed extensively in the me-
dulla, both in bones which present little or no outward evi-
dence of involvement, as well as in those presenting tumor-
like enlargements and marked deformity. In this fashion
tumors resembling fibromata may develop in which there
may be little or no bone formation. This process explains
the lengthening that sometimes occurs in the deformed long
bones.

von Eccklinghausen has demonstrated that in addi-
tion to transformation into osteoid tissue, the fibrous marrow
may manifest either regressive or progressive changes. The
regressive changes may lead to the smooth walled multilocular
cysts, containing either a serous or gelatinous substance and
occurring chiefly in tli£ long bones, but also occasionally
seen in the skull. The progressive changes lead to the forma-
tion of small brownish-red tumors with the structure of pig-
mented giant cell sarcomata, which also have their situation
in the long bones, but are always surrounded by the fibro-
osteitic tissue from which they take their origin. The exist-
ence of cysts in the fibrous medulla of certain cases hitherto
supposed to be instances of local osteomalacia makes it prob-
able that these were cases of osteitis deformans. Hirsch-
berg," in such a case, described in the neighborhood of the
cysts a small giant cell sarcoma. Certain of the cysts of
bones described in other connections may have their origin in

a condition of osteitis deformans. The cysts and sarcomata
in cases of osteitis deformans seem to indicate the situation of
the earliest changes in the medulla.

von Eeckliughausen has especially emphasized the role
played by the action of so-called physiological concussion in
the determination of the localization of osteitis deformans,
as evidenced by the tendency to involvement of the long
bones of the extremities. The newly-formed fibro-osteitic
tissue is most marked at the diaphysis of the bones which
are the points subjected to the greatest physiological con-
cussion, von Eeckliughausen is also of the opinion that the
frequent involvement of the skull may find its explanation in
disturbances of circulation, especially arterial congestion, re-
sulting from the action of mechanical and thermic influences.

The two most important factors then concerned in the
production of the deformity of the bones are:

(1) An hypertrophy of the bone.

(2) A relative softening which accompanies the onset and
which appears to be only temporary, being followed usually
by induration.

Chemical analysis has shown that the phosphorus is but
slightly diminished in the affected bones. The organic
matter of the bone as a whole is slightly above normal, while
the inorganic is slightly below normal.

In some of the cases reported careful blood examinations
have been made, but these have been negative in every
instance.

Concerning the etiology of osteitis deformans practically
nothing is known. Sex and heredity do not seem to play a
role. The venous dilatation seen in certain cases may be
an etiological factor, although this seems improbable.

Eichard, in his thesis published in 1887, advanced the
view that osteitis deformans is closely related to arthritis
deformans. Although in a few instances the two diseases
may have co-existed, there is no reason for assuming any
definite relationship between them. Eichard attempted to
distinguish three varieties of osteitis deformans.

(1) Those cases in which there are no lesions of the joints,
i. e., the type described by Paget.

(2) Cases in which both the shafts and joints are affected.

(3) Cases in which arthritis deformans is associated with
osteitis deformans.

Although frequently assumed, there has never been any
positive proof adduced to show that osteitis deformans is
dependent upon lesions of the peripheral or central nervous
system. In a few cases, lesions of the central nervous system
have been demonstrated at autopsy, as in the two cases of
Griles de la Tourette and Marinesco " and in the case of
Levi,"" in all of which marked degenerations of the tracts of
the spinal cord were demonstrated. It is, however, probable
that these were mere coincidences, for in many cases the
spinal cord, sympathetic system and peripheral nerves have
been carefully studied without the discovery of any lesion
that would explain the disease.

Lancereaux adheres to the view that diseases of the ner-
vous system play a role in the etiology of osteitis defprmans,

346

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

basing his ideas upon the fact that the bones present the
same characteristics as are seen in the bones of an extremity
after section of the nerve governing that extremity.

Schiif°' has demonstrated that section of the sciatic and
crural nerves in young dogs is followed in throe or four
months by a thickening of the tibia, fibula and bones of the
feet. The medullary canal is obliterated and osteophytes
develop upon the sm-face of the bones. In older animals
an osteoporosis develops at first, and after a year or so an
hypertrophy of the bone occurs. These experiments have
been confirmed by Vulpian and Philipeaux,^ but Vulpian
calls attention to the fact that changes in the bone do not
invariably follow section of the nerve.

The consensus of opinion seems to be that there is no
definite relationship between diseeises of the nervous system
and osteitis deformans.

The disease usually develops in individuals past forty years
of age and most frequently begins in the tibifE or the bones
of the skull. Gradually other bones may become affected,
but there appears to be an especial tendency to involvement
of the long bones of the lower extremities, the skull and the
clavicles.

The affected bones increase markedly in size and appear to
be more or less nodular; the firmness of the bones is dimin-
ished and those subjected to the action of weight or pressure
become deformed. In characteristic cases the parietal bones
become more prominent, the occipital bone is distinctly
enlarged, the temporal fossae are less marked and the frontal
bone overhangs the face. The curves and size of the clavicle
are increased. The thorax assumes a globular shape. The
arms appear to be relatively too long and frequently show
deformities, especially the forearms. Dorsal kyphosis is not
uncommon. Scoliosis is, however, quite rare. The pelvis
is often enlarged and the brim is everted. The trochanters
are higher than normal, as a result of their hypertrophy and
the more horizontal position of the neck of the femur. The
femurs are hypertrophied and curved, the convexity being
outward. The jjatellffi may be hypertrophied. The tibise
are massive with rounded edges and present curvatures with
the convexity outward and forward. The legs are usually
involved symmetrically, although the process may affect only
one or a few bones and remain localized in them. In ad-
vanced cases the posture of the patient is characteristic. As
a result of a bending of the vertebral column and lower
extremities the individual becomes shorter. The apparently
excessively long arms, the unsteady gait, the bowed knees,
the roimd shoulders and the head inclined forward give to
the individual somewhat of an ape-like appearance.

More or less pain often accompanies the development of
the earliest deformities, and it may also be very intense before
any deformity has occurred. At times the pain manifests
more or less of a periodical character, occurring at night or
after fatigue.

The pain of onset is usually the most severe, occurs both
day and night and either spontaneously or as a result of pres-
sure, and may be mistaken for rheumatism or neuralgia. As

the disease progresses the pain tends to become less severe
and may only be caused by exercise or humid weather.

Durverney in IT'S?, in discussing the pains of the initial
stages of rachitis, believed them to be due to a distension of
the periosteum, and this would also seem to explain the pains
of osteitis deformans. As has already been remarked, the
pains in osteitis deformans are most pronounced during the
early stages of the disease when the bones are imdergoing
hypertrophy. Later on, when the hypertrophic process
seems to be arrested, the pains are apt to disappear.

As for the general pains, abdominal, lumbar, etc., the
neuralgia, migra.ine and vertigo which occasionally occur,
they may be explained by the pressure of the hypertrophied
skull or vertebrae u]ion the brain, cord or nerves.

On the other liand there are certain cases in which pain
does not occur in spite of the very evident lesions of the
bones. This may be explained by a very slow development
of the disease in which instance the periosteum would be
but slowly and slightly distended.

Joncheray distinguishes two varieties of osteitis deformans:
(1) a painful variety and (2) a painless variety. The painful
variety is the more frequent and presents the more marked
lesions, while the painless variety develops more slowly and
with less intensity. The progress of the disease is slow, from
five to fifteen years being usually necessary to produce the
maximum changes. The condition of the patient is usually
very satisfactory, the general health as a rule is good and
there is nothing in the nature of the disease which need
necessarily shorten life. Among the complications that may
intervene may be mentioned a slight tendency to fractures
of the affected bones. The occurrence of visceral carcinoma
in association with osteitis deformans has also been noted.
It is doubtful, however, whether this is more than a mere
coincidence.

Among the conditions from which osteitis deformans is
to be differentiated may be mentioned: (1) Simple hyper-
ostoses, (2) Hyperostoses as a result of an excessive blood
suppl}', (3) Hyperostoses of elephantiasis, (4) Inflammatory
or traumatic hyperostoses, (5) Senile osteoporosis, (6) Osteo-
myelitis, (7) Syphilitic hyperostoses, (8) Hydrocephalus, (9)
Chronic rheumatism, (10) Acromegaly, (11) Pulmonary osteo-
arthropathy, (12) Leontiasis ossea, (13) Eachitis, (14) Osteo-
malacia.

Osteomalacia presents certain points of resemblance to
osteitis deformans. In osteomalacia, however, the absorp-
tion process is much less marked and furthermore in osteitis
deformans one does not find areas of decalcification of the
bone tissue which is the most characteristic feature of osteo-
malacia. It must, however, be admitted that a certain pro-
portion of the tissue in osteomalacia is new formed.

Osteitis deformans differs from rachitis in that the latter
is a disease of the growing bone in which changes occiu-
chiefly in the zone of growth and the ends of the bone; such,
however, is not the case in osteitis deformans.

Leontiasis ossea is a disease of younger individuals in which
there are marked hyperostoses not only of the bones of the

November, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

347

skull but also of the face. This marked thickening of the
bones lessens the capacity of the skull cavity and narrows all
the fissures and openings of the skull, as a result of which
there may be more or less marked disturbances of the cranial
nerves, and deafness and loss of smell may ensue. Ana-
tomically there is a marked sclerosis of the bone tissue, all
of which characters serve to differentiate the disease from
osteitis deformans.

Acromegaly is also a disease of younger individuals char-
acterized by an enlargement of the bones of the face while
the skull is not involved. There is also an hypertrophy of
the bones of the hands and feet without marked deformity
and with little or no involvement of the long bones.

The treatment of osteitis deformans consists in relieving
the pain and supporting the general health of the patient.
There is no known method of arresting the process or pre-
venting the deformities.

In the service of Dr. Morrow and subsequently in that of
Dr. Macdonald at the Albany Hospital it has been possible
to carefully study the following case:

J. H. G., age 45; nativity, England; occupation, book-
keeper.

Complains of fracture of the right arm and bowing of legs.

Family History. — Father died of heart disease at the age
of 65. Mother died of uterine trouble, at the age of 55. Six
brothers, all dead, causes unknown. Four sisters, all dead,
three in infancy, one of Bright's disease. No family
history of any trouble similar to the patient's present con-
dition.

Personal History. — Usual diseases of childhood. Had a
fever for two weeks, at 17 years of age, which he thinks was
typhoid. No history of malaria or pneumonia. His gen-
eral health has always been good until the onset of his
present trouble. Has taken alcohol moderately in the form
of beer, wine and whiskey. Denies syphilis and gonorrhoea.
Smokes and chews moderately. Has been a rather hearty
cater. Has never done much hard work and has never been
exposed to the weather. No history of bowel or bladder
trouble, and no history of previous fractures.

Present Illness. — Began in June, 1888, with a sharp pain
in the left knee. Prior to this time the patient had never
had any severe pain in the bones or Joints. This pain lasted
aliDut 12 days, during which time the patient was in bed.
The knee was somewhat swollen. The patient says he does
not think he had any fever. After this attack he was per-
fectly well for about four years. In February, 1893, the
patient had a second attack of pain in the left knee, accom-
panied by some swelling of the joint. In a few days the
other knee joint, both ankle joints, both shoulders, both
elbows, both wrists and hands, as well as the vertebral joints
became involved. The joints were swollen but the patient
says he had only slight fever and no sweats. He was in the
St. Peters Hospital T. r about four months and appeared to
have recovered completely, there being no further trouble
in the joints. The diagnosis made at that time was articular
rheumatism. The patient returned to work in July, 1892,

but says that about that time he first noticed that his legs,
which had always been perfectly straight, were becoming
slightly bowed. The patient thinks the bowing at first was
outward, and that the bowing was more marked in the left
leg. This bowing of the legs has gradually increased up
to the present time, and during the past three or four years
he has noticed that an anterior bowing of the legs has also
developed, which has gradually increased, but more slowly
than the outward bowing. He has had more or less pain in
the bones of the legs and in the knee joints during the past
eight years. He has also had some pain in the bones of the
arms and in the other joints of the body, but his trouble
has been confined mainly to the bones of the legs and the
knee joints. He says that the pains are usually of a sharp,
shooting character, but there have also been dull pains in the
bones and joints. The pain has never been severe enough to
incapacitate him for work since the attack in 1892. The
motion of the joints has not been impaired, except during
the two attacks mentioned and the patient has been able to
walk and get around without difficulty. The patient says
that his height before the onset of his present illness was
five feet, seven inches; his present height is five feet, one and
one-fourth inches. About 1893 he thinks his head began
to enlarge so that he was compelled to wear a larger sized
hat. He says in 1892 he wore a 7-} hat, but that during the
four years from 1892 to 1896 he was compelled to gradually
increase the size of his hat to 7f, which size he has worn
since 1896. He has never had severe headache nor any
special pain in the bones of the skull. His general health
has been good and he has attended to business regularly. He
has never noticed any bowing or deformity of the arms.

On April 2, 1900, the patient fell two and one-half feet;
struck on the shoulder and sustained a fracture of the neck
of the humerus. He has been unable to use the arm since.
He came directly to the Albany hospital, where the arm was
put up in splints and kept in splints and plaster until June
16th, without any evidence of union between the fragments.
On June 16th an attempt was made to wire the fragments,
but owing to the much softened condition of the bone the
operation was very imsatisfactory. At this time a fracture
just above the condyles of the humerus was discovered which
was undoubtedly produced during the operation and which
demonstrated the friable condition of the bone. The arm
was put up in plaster which was removed on July 2d, at
which time there was a slight evidence of union. On July
16th, examination of the arm showed that union had taken
place at the sites of both fractures. Examination on August
2d, showed that the union was fairly firm with a moderate
amount of callus and a slight deformity at the site of the
lower fracture. The elbow, wrist, metatarsal and phalangeal
joints were so stiff that movement of the forearm, wrist or
fingers was impossible.

Physical Examination. — Fairly well developed, somewhat
emaciated man. The shoulders are somewhat stooped, due
to a slight dorsal kyphosis. Skin and mucous membranes
of good color. Tongue clean, protruded in the median line.

348

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

Pupils midwide and equal, react to light and accommodation.
Chest somewhat barrel-shaped. The sternum is protuberant.
The right clavicle is distinctly enlarged and somewhat rough-
ened, the edges are rounded. Left clavicle is slightly en-
larged. Percussion note over the chest hyperresonant.
Breath sound clear. Pulse 73 to the minute, regular in rate
and rhythm, of fair volume and low tension. The wall of
the artery is palpable.

Heart. — Area of cardiac dullness normal. On ausculta-
tion a soft systolic murmur is heard at the apex following
the first sound, not transmitted to the axilla. Second sound
is clear at the apex. Heart sounds are clear at the base.

Abdomen negative. Genitalia negative. Superficial and
deep reflexes normal. No clonus.

Viewed anteriorly the skull appears fairly symmetrical.
There is a distinct massiveness and prominence of the
forehead, the frontal and parietal bones being apparently
much enlarged. There is a striking disproportion between
the size of the head and the face. Viewed posteriorly there
is a distinct asymmetry of the skull produced by an irregular
enlargement of the occipital bone, which presents irregular
jDrominences. On palpation the frontal, occipital and both
parietal bones appear to be distinctly thickened and enlarged.
The thickening and enlargement are most marked in the
occipital bone. The external surfaces of these bones are
somewhat irregular; they are very firm, and the scalp cover-
ing them appears to be normal. No tenderness can be
elicited on pressure over these bones. There is no apparent
enlargement or asymmetry of the bones of the face. The
teeth are somewhat decayed, but regular.

Measurements of the Skull. — From glabella to occipital
protuberance 21^ cm.; bi-parietal diameter of skull 16 cm.;
bi-temporal diameter of skull 15;J cm.; greatest transverse
diameter of skull is 17 cm. in a plane 2 cm. posterior to ex-
ternal auditory meatus; circumference of skull 62J cm.

There is a most marked bowing of the legs, the bowing of
the left being somewhat more marked than that of the right.
When the patient stands erect with the heels together there
is a distance of 4| cm. between the internal malleoli and
16^ cm. between the internal condyles of the femurs. The
bowing outward is most evident in the lower portion of the
femurs; somewhat less evident in the upper portion of the
tibije. There is also a well marked anterior bowing of both
femurs. Both the anterior and the outward bowing are most
marked in the left femur. On palpation both femurs are
found to be distinctly enlarged throughout their entire ex-
tent. The surface of the bones is somewhat irregular and
roughened but very firm. The enlargement of the trochan-
ters and the lower extremities of both femurs is most strik-
ing, although there is also evident enlargement of the dia-
physes. The circumference of both legs at the condyles of
the femur is 34J cm. Both tibisE present most marked en-
largement, especially in the upper portion; and are rough-
ened and irregular but very firm. Both fibula appear nor-
mal, except that they have participated in the bowing.

Pressure over the femurs elicits some tenderness, which ap-
parently is not localized in any particular part of the bones.
In none of the involved bones is there any evidence of tumor
formation. Radiographs of both femurs and both tibiae
show marked enlargement of the bones associated with
irregularities of contour. External rotation and abduction is
slightly limited in both hip joints. Other motions at the
hip joints arc normal. The motions in the knee joints are
normal. The scapula3 are normal. The left humerus is
straight and apparently normal. The right humerus pre-
sents a distinct thickening in the region of the surgical neck
due to a callus formation, and a slight deformity just above
the condyles of the humerus, due to a slight anterior dis-
placement of the upper fragment of the humerus, and the
presence of a moderate amount of callus. Union of the
fragments both at the surgical neck, as well as above the
condyles of the humerus, is firm. Both the radii and both
ulnce are normal. The bones of the hands and of the feet
are normal. The vertebrje are normal.

The muscles of the entire body, but especially of the legs
are atrophic. There is no evidence of involvement of the
central or peripheral nervous system.

The most prominent characteristics of this case, then, are
an extensive hypertrophy and bending of both femurs and
both tibiff, an hypertrophy of the frontal, occipital and both
parietal bones, and an hypertrophy of the right clavicle, to-
gether with fracture of the right humerus which is evidently
involved in the process, although not manifesting any evident
hypertrophy.

In conclusion it may be said:

(1) That osteitis deformans is a chronic disease of the
bones which develops in middle life or later.

(2) That the disease is of more frequent occurrence than
generally supposed.

(3) That the onset is insidious sometimes in a single bone,
but usually manifesting a tendency to symmetrical involve-
ment of tlie bones.

(4) That there is an especial tendency to involvement of
the tibia and femur as well as the frontal, occipital and
parietal bones.

(5) That it attacks both sexes and does not appear to be
related to any constitutional disease.

(6) That the etiology is not understood.

(7) That it requires from five to fifteen years to reach its
maximum dcvelopmont.

(8) That it is characterized by hypertrophy and deformity
of the bones involved, either with or without pain.

(9) That it is characterized microscopically by a rarifying
osteitis combined with new bone formation.

(10) That the duration of the disease is indefinite, and
that the disease has but comparatively little influence upon
the general health, and furthermore that it is not a direct
cause of death.

(11) That treatment must be purely symptomatic.

THE JOHNS HOPKINS HOSPITAL BULLETIN, NOVEMBER

1901.

PLATE XXXIX.

Fig. 1.

Fig. 3.

Skiagraph of Left Femur.

November, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

349

(1) On a form of chronic inflammation of bones (osteitis
deformans). Med. Chir. Transact., Vol. 60, p. 37, 1877.

(2) Saucerotte. Melanges de Chinirgie, Paris, 1801.

(3) Eullier. Bull, do Tec. de Med. de Paris, 1813, t. ii, p.
9i.

(4) Scoutetten. Osteomalaxie circonscrite. Gaz. Med. de
Paris, p. 428, 1894.

(5) Wrany. Prager Vierteljahreschrift, 1867, Bd. i. p. 79.

(6) Mosetig. Ueber Osteohalisteresis. Wiener Med. Presse
S. 89, 1868.

(7) Wilks. Trans. Path. Soc. xx, 1868-9, p. 273.

(8) Czerny. Eine lokale Malacie des Unterschenkels.
Wiener Med. Wochenschr. S., 894. 1873.

(9) Benno Schmidt. Ein Fall von Ostitis deformans. Arch,
d. Heilkunde. Bd. 15. S. 81, 1874.

(10) Volkmann. Entziindimgen der Knochen imd
Gelenke. Beitrage Z. Chir. S., 137, 1875.

(11) Eichard. Contribution a I'etude de la maladie
osseuse de Paget. These, Paris, 1887.

(12) Thibierge. Archives gen. de medicine, Feb. 17, 1893,
and Bull, de Soc. Med. des hop. de Paris, Feb. 17, 1893.

(13) Joncheray. De I'osteite deformante. These, Paris,
1893.

(14) MacPhedran. Med. News, Vol. xlvi, p. 617, 1885.

(15) Gibney. New York Medical Record, 1890.

(16) Mackensie. Medical Press and Circular, Vol. 51, p.
570, 1890.

(17) Taylor. New York Medical Record, Vol. xliii, p. 65,
1893.

(18) Watson. Bulletin of Johns Hopkins Hospital, 1898,
p. 133.

(19) von Recklinghausen. Die fibrose oder deformierende
Ostitis, die Osteomalacic, etc. Festschr. d. Assistenten f.
Virchow, 1891.

(20) Stilling. Ueber Ostitis deformans. Virchow's Ar-
chives. Bd. 119. S. 543, 1889.

(21) Biitlin. Cited by Paget.

(22) Lancereaux. Traite d'anatomie Pathol. Tome iii. p.
54.

(23) Silcock. A case of osteitis deformans. Pathol. Soc.
Transactions, Vol. 36. p. 383. 1885.

(24) Hirschberg. Zur Kenntniss der Osteomalacic und
Ostitis malacissans. Ziegler's Beitr. bd. 6. S. 511, 1889.

(25) Gilles de la Tourette and Marinesco. La lesion me-
dullaire de I'osteite deformante de Paget. Nouv. Iconogr. de
la Salpetriere T. viii p. 205, 1895.

(26) Levi. Un cas d'osteite deformante de Paget. Nouv.
Iconogr. de la Salpetriere T. x p. 113, 1897.

(27) Schiff. Comptes rend, do I'academie des sciences,
12 June, 1854.

(28) Vulpian and Philipeaux. Legons sur I'apparell
Vasomoteur Tome ii p. 352.

TUBERCULAR DACRYOADENITIS AND CONJUNCTIVITIS, CONTAINING THE REPORT OF
PROBABLE CASE ENDING IN SPONTANEOUS RECOVERY AND A REVIEW OF THE
PREVIOUS LITERATURE ON TUBERCULAR DACRYOADENITIS.

By Edward Stieren, M. D., Pittsburg, Pa.,

Assistant in Ophthalmology, Medical Department, Western

University of Pennsylvania.

Twelve years ago Cornet made the declaration that at least
one-third of all mankind are, or have been, afPected with
tuberculosis, not including in this sweeping assertion tuber-
cular invasion of the bones and joints, of the skin and glands,
and the various bidden depots of the disease. In 4250 suc-
cessive autopsies made in Breslan in the year 1893 gross
lesions of tuberculosis were found in 1393, or one-third of
all the cases. Brouardel found characteristic lesions in
seventy-five per cent of his cases at the Paris Morgue.^

Notwithstanding the great prevalence of tuberculosis in
the human race, the eye appears to enjoy a greater freedom
from tubercular invasion than any other part or organ of the

body. Thus, among 2100 ophthalmic cases observed in hos-
pital and private practice by Grant, not one was diagnosed
as being directly due to the action of the tubercle bacillus."

In 1867, Virchow considered the conjunctiva immune to
tuberculosis and in 1870 the first cases of tuberculous con-
junctivitis were reported."

This comparative immunity of the eye to tubercular in-
vasion is due in part to the facts that the eye is almost con-
stantly exposed to a lower degree of temperature than that
in which the tubercle bacillus thrives; is very often exposed

1 Whittaker, Tuberculosis. Americaa Text-Book of Applieil Thera-
peutics. 1896.

2 Grant, L. Observations on tlie relative frequency of tubercular
diseases of the eye, Caledonian Medical Journal. Glasgow, lS9y-iy00,
iv, 50-55.

8 Grunert. Archives of Ophtlialniology, xsviii, 1899.

350

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 128.

to the direct sunlight; is constantly bathed in and flushed
by the tears; and expulsion of germs from the conjunctival
sac is aided by the movements of the lids. To this may be
added the fact that the epithelial structure of the exposed
parts of the eye (epithelium resting on a basement mem-
brane), affords the bacillus very little opportunity for in-
vasion and growth.

Grunert * is pleased to regard tuberculosis of the conjunc-
tiva as a local disease. Van Duyse ° regards tuberculosis of
the lachrymal gland as hematogenous. Lodato believes tu-
bercular invasion of the lachrymal gland to be ectogenous."

Of all the structures or adnexa of the eye, the lachrymal
gland enjoys the greatest freedom from disease.

William Lawrance in over 40,000 eye cases in the Clinic
at Moorfields did not find a single afEection of the lachrymal
gland.

Acute dacryoadenitis was first described by Gayet in 1874.

Chronic dacryoadenitis (better known to the earlier oph-
thalmologists than the acute form), although still quite rare,
occupies a place in pathology, being due usually to either
small-pox, mumps, influenza, leucocythasmia, syphilis or
chronic trachoma.'

Tubercular disease of the lachrymal gland is one of the
rarest of eye affections, twelve cases being on record in the
Index Jledicus and in the Catalogue of the Library of the
Surgeon-General, TJ. S. Army. De Lapersonne ' describes
a woman who came to him for the relief of a ptosis and a
swelling at the upper outer angle of the orbit of the right
eye which had existed for three months. Tuberculosis was
not at first suspected although the patient had previously
had a cough with ha?moptysis and fever, and had lost in
weight. Treatment had relieved her of these symptoms, and
on presentation only a little rough breathing coiild be heard
over the left apex. On palpating the lid, the swelling was
found to consist of a tumor immediately under the skin, of
fibrous consistency and irregular outline. It was extirpated,
microscopical examination showing it to be without doubt
tubercular in structure. Erlich's stain did not demonstrate
tubercle bacilli. L. Miiller' reports two eases. One, a four-
teen-year old patient in whom the condition had existed for
four years. He presented himself with a redness of the
upper right lid and a swelling of the outer superior margin
of the orbit. Microscopical examination of the extirpated
tumor showed it to be typically tubercular with tubercle
bacilli present in great numbers. Miiller's second case was
a forty-year old man, the clinical picture being much the
same as in the previous case. A tumor about the size of a
hazel-nut occurred on the left side, lay quite deeply, and was

* Loc. cit. 5 Loe. cit.

'Lodato, G. Tubercolosi priraaria dell ghiandola lagrimale. Arch,
di ottal. Palermo, 1896, iv, 383-396.

' Baquis, E. Das Trachom der Thrlinendriise etc. Beitrag zur path.
Anat. und zur allgemein Path. Jena 1896, xix, 406-432.

STuberculose prob. de la gland lacrymale. Archiv. de I'ophthalm.
1893, xii.

9 tleber primare Tuberculose der Thranendriise. Beitriige zur Chiruro-ie-
FestschrUt fur Billroth. 1893, p. 144.

freely movable. Microscopical examination showed typical
miliary tuberculosis and tubercular infiltration, with some
few tubercle bacilli present. Baas " reports two cases. The
first, a sixty-nine year old man with no previous history of
tuberculosis. For six weeks he had observed a gradually
growing tumor in the left upper lid. ' On palpation, a growth
the size of a large hazel-nut could be felt, of elastic con-
sistency, smooth, and extending almost to the outer canthus,
interfering with external movement of the eye-ball. The
extirpated tumor proved to be typically tubercular, though
no tubercle bacilli could be found in the tissues. Baas'
second case was that of a thirty-two year old man who since
childhood had been affected with nasal catarrh, his nose
becoming gradually less pervious to air. A growth was re-
moved from his nose and diagnosed tubercular. For three
months the right eye had been red, with pain in the region
of the lachrymal gland and a growing tumor in this region
from which he sought relief. Tumor was the size of a cherry,
composed of small nodules, was freely movable, and could be
mapped out on all sides. It was hard, and on its outer aspect
a smaller, flatter hard mass could be felt. The eye-ball was
undisturbed in its movements, and the ocular conjunctiva
was much injected. A quarter of the extirpated tumor in a
horizontal section had the appearance of normal lachrymal
gland. The outer three-quarters was a hard, compact mass,
in which with the naked eye large and small nodules could
be seen, microscopically proving to be tubercles. Examina-
tion for tubercle bacilli was negative. Siisskind, J.," reports
a girl twenty-one years old, who for about two and one-half
3'ears had observed a tumor in her left upper lid. For a
year the tumor had not increased any in size. The skin of
the lid over the tumor had the appearance of telangiectasis
with marked ptosis. On superficial palpation the tumor ap-
peared soft and spongy, but on firm pressure a hard mass
could be felt, disappearing under the rim of the orbit. The
tumor appeared to have a pulsation, due to the well formed
vessels in the lid. Patient had enlargement of the cervical,
inguinal, and preauricular glands. The lachrymal gland and
the preauricular glands were removed, and in them, on micro-
scopical examination, were found epithelioid and lymphoid
tubercles, containing tubercle bacilli.

Siisskind thinks his case remarkable for the reason that the
preauricular glands were affected at the same time with the
lachrymal, and because the disease ultimately extended to
the parotid gland. Abadie " saw a case of double tubercular
dacryoadenitis in 1894. Some time later a similar case oc-
curred in the clinic of Prof. Manz in Freiburg," and one in
the practice of Salzer." Ziegler verified the microscopical

"Tuherkulose der Thranendriise. Archiv f. Augenheilk. 1894, Bd. 28.

" Kliuischer und anatomischer Beitrag zur Tuberculose der Thranen-
driise. Archiv f. Augenheilk. Wiesbaden, 1896, xxxiv, 231-229.

•'- Axenfeld und Fick, Pathologie des Auges. 1898.

'sUber einige tuberkulose Entziindungen des Auges. Munich, med
Wochenschrift. 189,5.

'■' Ein Beitrag zur Keutniss der Tuberkulose der Thranendriise. von
Graefe's Archiv, Bd. xl, Abtb. v.

NOVEMBEH, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

351

diagnosis in the latter case. The tumor was 1.8 cm. long,
1 cm. wide, and quite flat; edges round, irregular in size, and
divided into lobes. It had the appearance of a normal gland
hut on microscopical examination miliary tubercles, abundant
round cell intiltration, concentrically arranged around the
tubercles were found. Lymphoid tubercles were absent, nor
could any tubercle bacilli be found. Lodato " found in a
fifty-two year old woman a lachrymal gland tiunor the size
of an almond; hard, nodular, and freely movable, on section
])roving to be typically tubercular. Tubercle bacilli could
not be found in the gland. Van Duyse'" describes a case of
attenuated tuberculosis of the lachrynuil glands with sponta-
neous recovery. A girl, a?t. 19, anajmic and scrofulous, pre-
sented herself with a swelling in the superior lids of both
eyes. No jiain, inflammation, nor redness. On palpation a
tumor of cartilaginous consistency was felt on either side
wliich could be made to disappear under the rim of the orbits.
A portion of one was excised for microscopic examination,
the clinical diagnosis of sarcoma having been made. Pend-
ing the result of this examination the patient was given iodide
of potassium in fifteen grain doses, three times daily. She
jirosented herself six weeks later with a total disajipearance
nf all induration in the region of the lachrymal glands. In
tlie meantime microscopical examination of the excised por-
tiiin (if tlie gland showed it to lie tuljercular, tuliercle bacilli
aliscnt. Inoculation in the guinca-])ig was negative.

Van Duyse's resume is as follows: " Tuberculosis of the
lachrymal gland should not be considered primary; the infec-
tion seems to come from remote ])arts of the liody, being
hematogenous. Tulierculosis of the eye can be evolved under
an attenuated form and extinguish itself on the spot."

Tikanadze '' saw a case of tuberculous inflammation of the
lachrymal gland in 1897.

The following contril)ution to the literature on tubercular
disease of the lachrymal gland bears many features of Van
Duyse's case. Eose M., colored, a?t. 13, ])resented herself in
the Eye Clinic of the Medical Department, Western Univer-
sity of Pennsylvania, September 8, 1900, on account of a
swelling of hotli upper lids and an almost constant discharge
of matter from the eyes.

Fainihj history. — Rose is the only surviving one of five
children, the others having died in infancy; maternal uncle
died of consumption, paternal grandmother died in old age
and was affected with " cancer of the face " (probably lupus).
Both parents living and healthy.

Previous history. — Patient had measles at four years,
whooping-cough at six j-ears, and mumps at about ten years
of age.

Present iltiiess. — About three months before her appearance
in the clinic, patient began to have a cough, more severe at
night, accompanied with quantities of yellow expectoration.
Has been losing in weight only since that tinu\ and has had

night-sweats almost every night. Menstruation is irregular
and scanty. Aliout the same time her parents noticed an
increasing fullness and prominence of the upper lids accom-
panied by a more or less purulent discharge from the eyes.
There has been no pain connected with the disorder and no
discomfort except a slight burning sensation referred to the
outer canthi.

E.raiiiiiiatioii. Geiterah — Patient is a chocolate-colored
negress, almost five feet in height and weighs ninety pounds.
Is fairly well nourished about the face and neck but shows
marked emaciation about the trunk and limbs. Chest expan-
sion, one and one-half inches. Both parotid glands are
enlarged, tender, lohulated and movable. Both supraclavicu-
lar spaces filled with masses of enlarged glands. Thyroid
glands enlarged, right lobe most affected. Dullness well
marked with a tone and a half elevation of pitch over right
apex. Diminislied respiratory murmur and deficient expan-
sion over entire rigiit lunsi. Roughened breathing. ])ro-

'= Loc. cit.

'6 Tuberculose atti-iiiu-e des glauds lacrj mules; niK'risou sjioutauee.
Ann. de la Socit'te de nicdecine de Gand. 1896, Ixxv, Kl.'i-lUI.
" Vestnik oftalmol., Kiev., 1897, xiv.

Uilalerai lubercuhii Uacrvuadf nilis.

longed expiration, and subcrepitant rales over right supra-
clavicular and suprascapular regions. Pulse 130, tempera-
ture 99° at 3 p. m. daily. Cough worse at night, muco-
pul-ulent exj)ectoration; repeated examination negative for
tubercle bacilli. I'rine pale straw color, acid reaction. Sp.
Gr. 1009; no albumin, no sugar. I am indebted to Dr. George
C. Johnston for the al)ove clinical data, and agree with him
in his diagnosis of this case, viz., general tuberculosis.

Examination. Ocular. — On inspection, the upjier lid of
each eye presents a well marked and pronounced swelling,
with ptosis, entirely obliterating the infraorbital crease. The
summit of this swelling is at the outer third of each superior
lid and is slightly higher on the right side. On jialpation
the superior lids on light pressure feel soft and oedematous.

352

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 138.

the integument is freely movable and extremely lax. Firmer
pressure reveals a tumor iu each lid, hard, lobulated, rather
firmly attached at its base and disappearing under the rim
of the orbit. Each is joined to a flatter, equally hard, mass
below (the enlarged accessory glands), more marked in the
right lid.

The lids evert with difficulty and present a palpebral con-
junctiva, red, rough, and thrown into folds, dotted with
numerous yellow and yellowish-gray nodules. These nodules
are in many instances broken down in ulceration. The lower
lids are free from these nodules and ulcers although their
conjunctiva is inflamed and rough.

The ocular conjunctiva, excepting a few enlarged vessels,
is normal. Corner normal, with the exception of a slight
diffuse haziness, seen only with oblique illumination. Drain-
age apparatus unaffected. Inspection of the nose and throat
reveals nothing abnormal except a slight hypertrophic rhi-
nitis, common in this locality.

A quantity of the discharge and curettings from the ulcers
of the conjunctiva was collected, direct smears made on a
slide and search made for tubercle bacilli, repeated every
week, and always with a negative result. A portion of this
matter was injected into the anterior chamber of a rabbit,
with the result that in a few days the animal developed a
severe iritis. The eye was enucleated in fourteen days, the
iris examined for tubercular inflammation and tubercle ba-
cilli, with negative results. A watery solution of the matter
(about 3 cc.) was injected into the peritoneal cavity of a
guinea-pig, followed in three days with violent local reaction
from which the animal eventually recovered. Post-mortem
and microscopical examination in four weeks revealed noth-
ing tubercular, nor could a tubercular growth be cultivated
at any time in the various media from the matter serajied
from the lids.

The patient was given full doses of codliver oil and creo-
sote, taken from school and made to live an out-of-door life
as much as possible, with appropriate diet.

She was seen once or twice a week for a period of four
months, during which time the enlarged lachrymal glands
presented no change. The conjunctival ulceration improved
under the home use of a 2 per cent protargol solution and
application of a 2 per cent nitrate of silver solution at the
clinic.

About the middle of January, 1901, the condition of the
lachrymal glands was the same as when first seen, notwith-
standing the fact that the other glands of the body which
had been enlarged and tender, had become to all outward
appeai'ances normal. The conjunctivae were still rough and
presented many of the nodules as when first seen; the dis-
charge and ulcerations were, however, markedly less.

The patient was lost sight of for about two months. Hav-
ing received the advice to have the diseased lachrymal glands
removed, with the fear and superstition characteristic of her
race for any " cutting operation," she did not reappear in
the clinic until the middle of March, when she presented
herself much elated over the complete cure of her ocular
malady.

On inspection the lids presented a normal appearance;
their former fullness had entirely disappeared and it was
only with the most careful palpation that a small, hard,
scarcely perceptible gland could be felt by introducing the
tip of the little finger well under the rim of the orbit. The
everted upper lids showed a smooth glistening conjunctiva,
entirely free from nodules and ulcerations and with but a
slight degree of congestion. The general health of the
patient has correspondingly improved; she has gained
eighteen pounds in weight, is free from cough and night-
sweats, and has a healthy, bright appearance. Some rough
lireathing can still be heard over the right apex, but no
tubercle bacilli can be found in her much diminished expec-
toration.

The study of this and the twelve other reported eases
appears to warrant the following conclusions being drawn:

1. Tuberculosis of the conjunctiva may be either ecto-
genous or entogenous; tuberculosis of the lachrymal gland
must be hematogenous.

2. The presence of the tubercle bacillus in tuberculous
conjunctivitis and tubercular dacryoadenitis is not a sine qua
von of the disease. In the present case, repeated examina-
tion of the matter from the ulcers of the conjunctiva failed
to show tlie presence of tubercle bacilli, nor did inoculation
in animals produce the disease. Burnett" speaks of a ease
lie observed for more than a year, in which the clinical pic-
ture was one of tuberculosis of the conjunctiva, and yet he
could not find a single tubercle bacillus after repeated exami-
nations; inoculation in rabbits likewise proved negative.

3. Tubercular dacryoadenitis and conjunctivitis may un-
dergo cure; surgical intervention is indicated only after thera-
peutic and proper hygienic measures fail, since it is a uni-
versally recognized fact that tuberculosis in other parts of
the body is often cured outright spontaneously, the cure being
effected by a marked increase of connective tissue.

NOTICE,

The Committee on the Miitter Museum of the College of
Physicians of Philadelphia announce that the Miitter lecture
for the year 1901 will be delivered on Tuesday, December 3,
at 8 P. M., in the Hall of the College of Physicians. Dr.
Harvey Gushing, of Baltimore, will deliver tlie lecture, the
subject being " Some Experimental Observations Relative to
the Surgery of the Nervous System."

John H. Brinton,
George McClellan,
Frederick A. Packard,

Committee, Miitter Museum.

1* Diseases of the Conjunctiva and Sclera. System of Diseases of tbe
Eye. Noiris and Oliver. Vol. iii, p. 234.

NOVEMBEE, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

353

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JOHNS HOPKINS HOSPITAL BULLETIN.

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HOSPITAL STAFF OCTOBER J, 1901.

Superintendent ;
HENRY M. HURD, M. D.

Phtsician-in-Chief :
WILLIAM OSLER, M. D.

SuiiOEON-lN-CniKF :

WILLIAM S. IIALSTED, M. D.

GVNECOI.OGlST-IN-CniEF :

HOWARD A. KELLY, M. U.

Obstethician-in-Chief :
J. WIIITRIDGE WILLIAMS, M. D.

PATnOLOGIST:

WILLIAM II. WELCH, M. D.

Associates in Surgeut :
J. M. T. FINNEY, M. D., J. C. BLOODGOOD, M. D.

Associate in Medicine:
W. S. THAYER, M. D.

Associates in Gynecology :
W. W. RUSSELL, M. D., T. S. CULLEN, M. B.

Resident Physician :
T. McCRAE, M. B.

Assistant Resident Physicians:
R. I. COLE, M. D., C. P. EMERSON, M. I).

Resident Surgeon:
J. F. MITCHELL, M. D.

Assistant Resident Surgeons:
R. H. FOLLIS, M. D., M. B. TINKER, M. D.,

W. F. M. SOWERS, M. D.

Resident Gynecologist:
G. L. Hl'NNER, M. D.

Assistant Resident Gynecologists :
B. R. SCHENCK, M. D.,* J. A. SAMPSON, M. D.

C. F. BURNAM, M. D.*

Resident Obstetrician:
F. W. LYNCH, M. D.

Resident Pathologist:
W. G. MacCALLUM, M. D.

Assistant Resident Pathologists:
E. L, OPIE, M. D., W. B. JOHNSTON, M. D.

House Medical Officers:

F. H. BAETJER, M. D.,
T. R. BOGGS, M. D.,
J. I. BUTLER, M. D.,+
R. F. HASTREITER, M. D.,
J. M. HITZROT, M. D.,
J. M. SLEMONS, M. D,,
L. M. WARFIKLD, M. D.,

J. M. BERRY, M. D.,
C. H. BUNTING, M. D.,
H. A, FOWLER, M. D.,
J. H. HATHAWAY, M. D.,
M. J. RUBEL, M. D.,
U. N. SPRATT, M. D.,
S. H. WATTS, M. D.

Externes :
MABEL WELLS, M. D., C. K. WINNE, M. D.

♦Absent on leave.

tActing.

BULLETIN

THE JOHNS HOPKINS HOSPITAL

Vol. Xll.-No. 129.]

BALTIMORE, DECEMBER, 1901.

JAN 3 1-g^

[Price, 15 Cents.

•■'S' ry '■

CONTENTS.

PAGE

A Contribution to the Study of Amcebic Dysentery in Children.

By Samuel Ambers, M. D., 355

PAGE

Pathological Report upon a Fatal Case of Enteritis with Anemia

caused by Uncinaria Duodenalis. By Jous L. Taxes, M. D., . 066

The Advances made in Medical and Surgical Diagnosis by the

Rcjntgen Method. By Charles Lester Leonard, A. M., M. D., 363

Notes on New Books 372

A CONTRIBUTION TO THE STUDY OF AM(EBIC DYSENTERY IN CHILDREN.*

By Samuel Ambeeg, M. D.,
Assistant in Pediatrics, Johns Hophins University.

During fall 1900 and winter 1900-1901, 5 cases of amcebic
dysentery came under observation at the children's dej)art-
ment of the Johns Hopkins Dispensary, and were admitted
to the hospital in Dr. Osier's service, whose kind permission
enables me to -report them. In his paper on amcebic dysen-
tery Harris' comments upon the infrequency of the disease
in children and young adults, the proportion being about
10 persons above, to 1 under 20 years of age. Of his series
of 35 cases, 4 were under 10 years of age. There seem to be
only two more cases on record, where amoebfe were found
in children of the first decade of life in the U. S. Strong '
encountered amoebse in the tuberculous ulcers of the intes-
tines of a 3-year old child, and Slaughter ' in a liver abscess
of a boy 7 years of age. Of foreign authors Kurtulis' states
that dysentery befalls children of all ages with exception of
infancy. Kurtulis does not expressly say amcebic dysen-
tery, giving the division into the different types of dysentery
in the subsequent pages, biit amoebic dysentery is at least
included in his statement. Pfeiffer' found the amrebae in
the passages of several children. The child in whose passages
Lambl ' discovered the amoehoe for the first time, was 2 years
old, but the amoeba found in his case were much smaller
than those usually found in amcebic dysentery. Lutz ' men-
tions the occurrence of amceba? in the passages of a little
girl and Sonsino ' encountered them in the intestinal mucus
of a child. Neither mentions the age of his patient.

*Read before the Johns Hopkins Medical Society, January 7, 1901.

Cahen' reports a case of amcebic dj-sentery in a girl 4 years
of age and Gneftos" met the amoebse in material of a liver
abscess in a child 6 years of age.

In the following will be found short histories of our cases
as they came under observation.

Case 1. — Peter S., age 3 years, of Bohemian descent, came
to the dispensary on Oct. 18, 1900, and was admitted to the
hospital on Oct. 25th.

His complaints were pain in abdomen and bloody passages.
During the summer he used to drink water from the gutter.
His present illness began suddenly 2 months ago with fre-
quent passages containing mucus and blood. The move-
ments w-ere associated with some pain. After suffering for
8 days with these symptoms he got a medicine lessening the
frequency of the passage, but not the mucus or blood. There
was no loss of appetite.

At the examination of the well nourished, rather pale boy
heart and lungs did not present anything pathological. The
abdomen was slightly distended, not tender on pressure.
The edge of the liver was indistinctly felt, the spleen was
not palpable. The movements of the bowels were accompa-
nied by some pain. Patient was put to bed, received liquid
diet and was started with irrigations of 400 ccm. of a 1 : 5000
solution of sulphate of quinine 2 times a day.

On November 1, patient was taken home not improved.

The frequency of his passages, not counting the irrigations,
varied between 0 and 3. His temperature never exceeded
99.2,° mostly varying between 98° and 99°. After his dis-

356

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

charge the irrigations were kept up for a time at the dispen-
sary, but the patient soon failed to appear.

On the 19th of February, 1901, the patient presented him-
self for the se'jond admission.

The frequency of his passages had Taried between 4 and 5
in 21 hours and sometimes he had lost a considerable amount
of blood. The passages now contain pieces of blood-clots
of about 3 cm. length.

The child was well nourished and not particularly anemic.
At the physical examination nothing new was found. The
treatment consisted in rest in bed, dieting, irrigations of
quinine solution gradually increasing in strength from 1:5000
to 1:250 twice a day and bismuth subnitrate.

On April 6, the child left the hospital well.

The frequency of the passages never exceeded 5 in 21
hours. At the beginning of March the passages became more
and more solid and formed, the amount of mucus lessened,
and the blood disappeared. Since about a fortnight before
discharge the discharge never contained any more mucus,
blood or amcebse. The temperature during the first week
several times reached 100° ; the highest temperature of 101°
was noted on the 27th of February; it reached the normal
line the next day, varying henceforth between 97.5° and
99°.

Case 2. — John P., age 5 years, of Polish extraction, came
to the dispensary on the 29th of October, 1900, and was ad-
mitted to the hospital on the 30th.

His complaints were loose bowels and prolapsus recti.
Patient was born in Germany and came to this country 3
months ago. In September and October he spent 6 weeks
in the country, near Aberdeen, the rest of the time he lived
in Baltimore. The present illness developed while in the
country. There is no history obtainable of drinking stagnant
water. Patient was taken sick about 6 weeks ago after liv-
ing for two weeks in the country. It came on rather sud-
denly with very frequent movements of the bowels, the pas-
sages frequently containing blood. The movements often
were associated with severe straining. After a while the
intestine began to come down with the passages, but again
retracted shortly afterwards. Several times the child vom-
ited. During the last few days the patient had chilly feel-
ings and fever, but no definite chill. Appetite is poor.

The patient is a delicate, poorly nourished child. The vis-
ible mucous membranes are pale. The cervical glands are
slightly enlarged. There is a slight cedema of feet and legs.
The volume of the pulse is small, the rhythm regular. The
tongue is clear. Percussion and auscultation of the lungs
do not present any signs of disease. Over the whole heart a
soft systolic murmur is to be heard, which is loudest over the
apex. The abdomen is slightly distended and not tender on
pressure. The liver is just felt, the spleen not palpable.
The rectum prolapses with each passage about 4 cm. and is
inflamed. Ulcers are not seen. The rectum retracts after
some time. The passages are very painful.

Patient was put to bed, received liquid diet, and was
started on quinine irrigations twice a day. The strength of

the solution was gradually increased from 1:5000 to 1:350
until the 21st of January, 1901, when the irrigations were
stopped. From the 9th of December patient received as
morning irrigation 500 ccm. of a 1:20,000 silver nitrate-solu-
tion instead of quinine. Of other medications he received
bismuth subnitrate, which was changed later on to tannigen,
and syrupus ferri iodidi.

The prolapsus of the rectum was not noticed after the
second week in January. Towards middle of January
patient acquired a good color, and felt very well. On the
26th of January he was discharged well.

During the first month patient had as many as 17 passages
a day, but their frequency varied much; sometimes he had
only 3. For a period of about two weeks before his dis-
charge he had no more than 3 passages a day. After Jan-
uary 4, no more amcebaj were found. At the beginning of
January the passages became formed.

Until the end of November the thermometer registered
several times 100°, the highest temperature of not quite 101°
being noted on the 18th of November. From the end of
November the temperature can be considered as normal.

Case 3. — William K., age 5 years, white, came to the dis-
pensary on January 7, 1901, and was admitted to the hos-
pital on January 8.

The patient's complaint was about a prolapsus recti. Sev-
eral months ago, while picking strawberries in Anne Arundel
County, the boy was taken sick with diarrhcea, having 5-8
loose passages a day, containing blood. At the same time
his younger brother was affected in a similar way. Soon the
bowels came down with every passage. The child never com-
plained about pain or straining. The appetite was always
good and he continued to play around.

In material taken with the rectal tube fairly numerous
Charcot-Leyden crystals were found, but no. amoebae. The
next day patient came back with his brother, in whose stool
amcebse were readily found, while the presence of amcebse in
the stool of the first patient was demonstrated only after
admission to the hospital.

Upon examination, the boy seemed well nourished but a
little pale. He had enlarged tonsils. On the 15th of Jan-
uary the patient was discharged, somewhat improved, to con-
tinue treatment at the dispensary. He was treated with
irrigations of quinine. The mother brought him for a
time regularly to the dispensary, but soon preferred to
give him the irrigations at home. Up to the beginning
of March patient did fairly well, having from 0 to 5
pasty movements a day. He was shown at longer intervals
at the dispensary, where always motile amoebae were found in
his stools, with little blood and mucus. At the beginning
of March he grew gradually worse. The bowels moved more
frequently, the passages were loose, containing more blood
and mucus. The prolapsus, which had disappeared, came
back. Before his second admission on the 13th of March he
had vomited twice. His .appetite was poor. On the morning
of his second admission the yellow liquid stool contained an
enormous amount of amcebse. Over the base of the left lung

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

357

the breathing had a tubular moditication, and on inspiration
fairly numerous medium moist rales were to be heard. The
first heart sound over the apex was accompanied by a soft
systolic murmur. At the base the heart sounds were clear.
The abdomen was not tender on pressure; liver and spleen
not palpable.

Patient was put to bed and placed on the usual treatment.

On the 21st of May he was taken home against advice,
although motile amoebaj were found in his passages on day
of discharge. The patient's general condition was much
improved.

The frequency of the passages was 3 to 5 a day and their
consistency became gradually firmer.

The temperature curve remained mostly around the normal
line, the highest temperature of 100° was noted on the 4tli
of April.

Case 4. — ilichael K., age 2 years 8 months, white, came to
the dispensary on the 8th of January, 1901, and was admit-
ted to the hospital on the same day.

He complained about loose passages, containing blood. The
disease was contracted at the same time his brother was taken
sick, about May, 1900. Both were drinking pump-water. At
first he had 2 or 3 loose movements a day, but their frequen-
cy increased gradually until now, the mother says, his bowels
move nearly constantly. Blood in his passages was first
noticed two weeks after onset. Patient did not suffer any
pain and had always a good appetite. The child was fairly
well nourished, pale, a little puffy about his eyes. The
glands of neck, axilla and inguinal region were just felt, the
epitrochlears were not. Phimosis. The tongue is slightly
coated. The lungs are clear. Over the whole heart a blow-
ing systolic murmur was heard, which was not transmitted
into the axilla. The abdomen was a trifle full, not tender
on jiressure. Liver and spleen were not palpable.

He was ordered inngations of quinine.

Patient was discharged on the loth not improved, to con-
tinue treatment at the dispensary.

The number of passages varied between 1 and 4 a day;
they were rather loose. The temperature curve reached not
quite 100° on the first day and fell afterwards to the normal
line.

Patient was brought for a short time to the dispensary, and
afterwards received his irrigations at home. Until 21st of
May he was brought at longer intervals. Then the family
left for the country.

The frequency of his passages varied between 2 and 4.
Sometimes they were more formed, at others loose. He
never passed blood to a considerable amount. Motile amoe-
bae were seldom absent from his passages.

Case 5. — Mary R., age 4 years, white, came to the dispen-
sary on the 25th of Febiiiary and was admitted to the hos-
pital on the 26th.

Tlie patient complained of diarrhoea, blood in jiassages
and general weakness. The child was very fat before taken
sick. The disease lasted about 5 months. Sometimes she
had 5 to 6 movements a day. The passages sometimes con-

tained bright red blood. Child feels weak. Appetite was
always good. Patient is a playmate of Peter S. (Case 1) and
used to drink from the gutter too.

The girl appears to be well nourished and somewhat pale.

The examination of lungs, heart and abdomen did not re-
veal any patliological changes.

The child received the usual treatment and was discharged
well on the 24th of March.

The number of the passages never exceeded 3. On some
days she had no spontaneous passage. With the rather firm
stools there came at first a little mucus and blood. From
the middle of March no more amoeba were found.

The highest temperature, 100°, was reached on the 28th
of February. For the rest of the time the course remained
just above the normal line.

On examination of the urine no albimien nor sugar was
found in any of our cases, nor did it contain an extraordi-
nary amount of indican.

At the end of August, 1901, we inqiiired into the state of
health of our cases. John P. and Mary E. remained well.
The father of William and Jlichael, who were still in the
country, said the children did well and did not suffer any
more from diarrhrea, nor were blood or mucus present in
their passages. The statement must be taken with caution.
Peter S. enjoyed very good health until the beginning of
August, when he began to void blood after passing a formed
stool. I could not prevail upon his parents to bring him to
the liospitnl or dispensary.

The first factor of interest in our cases is their grouping.
In two instances the disease befell members of the same fam-
ily exposed to the same influences. Peter S. and Mary E.
were playmates living in close neighborhood and drinking
from the same contaminated sources. A third child of their
company was taken sick with the same symjjtoms, and it is
very probalile tliat this child, too, had amrebic dysentery.
Notwithstanding several efforts I was unable to obtain con-
trol over this last case.

The clinical type, to which our cases belong, is that of
moderate intensity as described by Councilman and Lafleur."
Harris ' gives a somewhat different clinical classificatioii aTid
places in his first group those of a very mild form, where the
appetite and general health are good. Fever and acceleration
of pulse do not exist worth mentioning. The number of
stools varies from 2 to 6 in 34 hours. This, he states, is the
usual form observed in children. With exception of John P.
the type of our cases coincides very closely with this descrip-
tion. John P. must be cla.«sed in the second group, that
of moderate severity, where the general nutrition is decidedly
interfered with. The patient's general condition will best
be illustrated by the blood-picture. There is frequently more
or less anorexia, the jndse is somewhat increased in frecjuoncy
and there are irregular exacerbations of temperature, partic-
ularly at night. The number of stools is from 8 to 15 in 24
hours. William T\., before his second admission, seemed to
be in a state of transition from the first grou]i to the second.

A ratlier surprising feature in the clinical picture is the

358

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

little amount of discomfort, which the children of the first
group experienced. None of the children, with exception of
Peter S., and he not to any considerable extent, complained
about any pain, even William K. was free from it, although
he had a prolapsus recti. Mary R. complained only of a
feeling of general weakness, which was not very pronounced
at the time she came imder observation. This circumstance
makes it difficult to impress the parents with the necessity
of putting the children to bed. Complete rest is a very
important factor in the treatment, at least in regard to
shortening the course of the disease. John P., a member of
the second groiip, seemed to suffer severely at the time of
his movements.

Of complications, we had in two instances a prolapsus
recti, which was a little smaller and not as much inflamed in
the case of William K. as compared with that of John P. In
both eases the prolapsus was reduced spontaneously, the re-
duction in the latter case requiring more time.

In none of the cases was any sign of affection of the liver.
Abscess of the liver, which is a rather frequent complication
of amoebic dysentery in adults, seems to be of very rare
occurrence in children. Unfortunately in the great majority
of the cases of liver abscess in children, which are reported
as following dysentery, there is no mention made of amoebre,
although, as Slaughter ° already mentions, in some of the
cases we may suspect an amoebic origin. Oddo," up to 1897.
collected 12 cases of liver abscess following dysentery in
children. From these cases there must be subtracted one
case mentioned by Leblond," that of Easmon," who does not
mention dysentery in the history of his patient. Further-
more, Hall " reported his case as one of traumatic abscess of
the liver. Neal," too, does not mention dysentery, but speaks
of the presence of round worms in the intestines. There re-
main the following cases, first 3 cases mentioned by Leblond,
those of (1) Miller (Transactions of Med. and Phys. Society,
Bombay, 1848). (2) Monger, dysentery ancienne. The ref-
erence given I was unable to find. (3) Pereira." He does
not give the age of the child. Then follow the two eases of
Legrand " in children, 5 and 3 years of age, as No. 4 and .5.
(6) Huybertz's" case in a 6 year old boy. (7) Slaughter's'
in a 7 year old boy. The cases of Chappie and Rosetti I
was unable to find. Besides these cases we find one (8) re-
ported by Johnston'" in a 13 year old girl, and one (9) by
Finizio " in a boy 6 years of age, and one (10) by Gneftos "
in a 6 year old child. Including the first 3 cases of Leblond
and those of Chappie and Rosetti, there are reported 12 cases
of liver abscess in children following dysentery. Of all these
cases mptile amcebag in material taken from the liver abscess
were found only by Slaughter, while Gneftos reports the
finding of dead amoebae. The dysentery had persisted for a
short time and no micro-organisms were grown from the ab-
scess. In some of the other eases amoebic origin of the liver
abscess is more or less probable. In the two amoebic cases
the abscess followed the dysentery in a short time, as it seems
to be the rule. Josserand°° and Laferrere" reported a
series of cases, in which several years had elapsed between

the dysentery and the coming on of the liver abscess, and
it remains to be seen, if this can happen in cases of amoebic
dysentery too.

The reaction of the feces was mostly alkaline, seldom
slightly acid. Sometimes in the acid stools the amoebae con-
tinued to move for 2 to 3 hours. The microscopical appear-
ance of the feces varied very much. In some instances they
were rather firm and formed, carrying some bloody mucoid
masses on the surface. Sometimes a formed stool was passed
followed by blood either liquid or, rarely, in clots, accompan-
ied by more or less mucus. In other instances the passages
were semi-solid or uniformly liquid of different color with
mucoid masses and blood intermingled. At times red blood
corpuscles were only detected at the microscopical examina-
tion. The odor of the feces was always very offensive. In
the cases of John P. and Peter S., and to a less degree in
that of Mary R., there appeared towards recovery in the
place of the mucoid masses stools of peculiar gelatinous
consistence, which were found to be composed of continuous
layers of epithelial cells.

The diagnosis was based upon the finding of motile amoebae
containing red blood corpuscles.

According to Harris' ' method the surviving amoebae were
stained with toluidin blue in watery solution. A suitable
piece of material is taken on a slide, a drop of the staining
fluid is added and then a coverslip put on, or particles of the
feces were put into the staining fluid and examined after
a while. The endosarc is stained blue, while the ectosarc
remains free or is stained later and less deeply. The only
exception we have to make to Harris' statement is, that the
amoebaj are by no means instantly killed by the toluidin blue.
In some of the specimens motile amoebae were found 3 to 4
hours after staining, even if the particles of feces had re-
mained for aliont 1 hour or little longer in a rather concen-
trated solution of the dye. In a number of the amoebae the
endosarc was stained very appreciably and still they contin-
iied to move. As a whole, it seemed that the more in-
tensely the endosarc was stained, the motility grew less,
until at a certain period the motility ceases, which occurs in
different phases of the movement, so that the amoebae appear
to be fixed in different shapes. Not in all instances did the
degree of staining and the ceasing of the motility coincide,
so that amosbfe with deeper stained endosarc continued to
move, while less deeply stained ones appeared fixed. The
vacuoles take the stain deeply and are hardly to be distin-
guished from the nucleus. In the lighter stained bodies the
red blood-corpuscles are not stained; in deeper ones they are
blue. The method is valuable only when applied to living
amcebfe.

A very good effect may be obtained by staining the sur-
viving amoebae with methylene-blue and neutral red. Either
of these may be applied in watery solution or in substance.
The only dift'erenee between these two stains seems to be, that
methylene-blue checks the motility of the amoebfe some-
what quicker than does the neutral red. As with toluidin-
blue, the endosarc takes the stain, while the ectosarc remains

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

359

free. If a drop of a watery solution of neutral red is added
on a slide to a particle of feces containing living amoebae,
there appear in the endosarc of those that are more distant
from the stain, and while the surroundings remain unstained,
a few round granules of different sizes stained red. The
granules emerge and disappear with the movements of the
amoeba;. Gradually more and more of granules take the stain,
while nucleus and vacuoles still remain free. Then the
margin of the nucleus seems to take the stain slightly, and
then the vacuoles begin to stain. In this state the rest of the
endosarc presents a more uniform and deeper staining. In
the still deeper stained specimens the endosarc is still more
uniformly stained, while nucleus and vacuoles do not stand
out clearly any more and are hardly to be distinguished from
each other. Under these circumstances the amoebfe have lost
their motility; they are mostly round, but some are fixed in
different phases of movement. The deep red endosarc is
sharply defined from the white ectosarc. The picture is
very striking. From the deeply red stained background the
white endosarc stands out very clearly. In some of the speci-
mens, perhaps dependent upon the reaction of the feces, the
endosarc is more yellow. The loss of the motility seems to
depend to a large extent upon the degree of staining. Some
of the amosbae, particularly when more diluted solutions are
used, preserve their motility for hours.

The red blood corpuscles in the amoebae remain for awhile
unstained, then they become of a brassy color, at last red.
The results obtained with methj'lene-blue are very similar.
These methods of staining are only successful with living
amcebfE. If the specimens are preserved, with the air ex-
cluded, they may keep for 24 hours. But, as a rule, the stain
is not persistent and after the lapse of a few hours the speci-
mens fade. Several attempts to preserve the specimens
proved unsuccessful. Arnold,^ whose paper gave the sug-
gestion of using neutral red and methylene-blue for our pur-
poses, was equally unsuccessful in preserving his specimens.

Many of the authors writing about amcebic dysentery men-
tion the occurrence of Charcot-Leyden crystals in the feces,
Kruse and Pasquale '^ found the crystals in material taken
from liver abscesses. Their presence in the feces of persons
suffering with helminthiasis is well known. More inter-
esting is their occurrence, where the intestines harbor para-
sites of a lower order. In our series the crystals were absent
only in the case of Mary E. In the passages of the other
children they were rarely absent, but their number varied
very much. Lewy " emphasizes that a close relationship
exists between these crystals and the eosinophile cells,
although it does not appear that this relationship is always
found (see Cohn,^ Brown ^° and Schmidt and Strassburger,"
these latter authors do not mention if in their examinations
of the feces the eosinophile cells were numerous). Brown "'
and Ewing" mention that in several instances numerous
eosinophile cells were found in the feces in company with
the crystals. The only report of the occurrence of eosino-
phile cells, besides the crystals, in the passages of patients
suffering with amoebic dysentery, is that of TJoemer." In our

cases, with exception of Mary K., where only a few eosino-
phile cells were found, eosinophile cells and tree eosinophile
granules were never absent, but their number was subject to
great variations. Sometimes a whole field contained hardly
anything besides these cells and free granules. Some
of the cells were mononuclear. The granides in the cells
and outside were sometimes very large. The number of the
cells was by no means always proportional to that of the crys-
tals. As staining fluid, the eosinate of methylene-blue (the
so-called Tenner stain, see Simon "" and Ewing '" — adden-
dum) proved very convenient. The crystals take a faint red
color with this staining fluid, which, it may be mentioned
here, does not offer any particular advantage for staining,
amoebae. I did not succeed in adapting Lewy's method of
demonstrating the association of the crystals with the eosino-
phile cells in tissues for the examination of the feces.

The picture of the feces was too inconstant to allow a
conclusion in regard to a relationship between the numbers
of amoeba;, crystals, and eosinophile cells. Nor was it pos-
sible to establish a distinct relationship between the number
of crystals and eosinophile cells in the feces and the number
of eosinophile cells in the blood, as will be seen later. Only
in the case of Mary E. the small number of eosinophile
cells and the absence of crystals coincide with an exception-
ally small number of eosinophiles in the blood. In the case
of John P. and Peter S., the crystals disappeared with the
disappearance of the amoebae and the eosinophile cells and
free eosinophile granules became much less numerous.
Monads were present in the stools of all the cases again, with
exception of Mary E. They resembled pears in their shape
with a flagellum at either end. They were not constantly
found and when found their number varied much. The
question arose, if there existed perhaps a relation between
these elements and the crystals and eosinophile cells. The
circumstances, that they were found rather inconstantly, the
examinations of the passages of two adults suffering with
amcebic dysentery, where crystals and eosinophile cells were
numerous in absence of monads, and the notes of Eoemer
make it rather doubtful. Furthermore, in the diarrhceic
passages of a child in the hospital an enormous amoxmt of
monads were present, while Dr. Boggs did not encounter the
crystals at repeated examinations. Eosinophile cells were
comparatively numerous.

It may be of interest to note, that the number of neutro-
phile elements in the passages, particularly well preserved
ones was mostly very small and they seemed mostly to be
less numerous than the eosinophile elements.

In specimens taken from the flrst passages of Peter S., a
number of distinct nucleated red blood corpuscles was seen,
and Dr. Futcher noted in a fresh specimen obtained from
Michael K., the occurrence of cells looking very much like
nucleated red blood corpuscles. In both cases the blood did
not contain normoblasts.

In regard to the presence of amcebas in the feces of chil-
dren suffering from other intestinal diseases, the negative ex-
perience of Cahen" was repeated. On microscopical exam-

360

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

ination of at least a few lumdred fresli specimens obtained
from children suffering with intestinal disturbances during
the last year, comprising the summer of 1900 and part of
the summer of 1901, amoeba! were never encountered. Eela-
tively few of the children were over 3 years of age. Al-
though these examinations were for the greater part not
made with the distinct purpose of watching for amccbffi, the
large number of examinations, frequently including repeated
examinations of the same individual, would not have given
a negative result, if amcebffi were of frequent occurrence in
intestinal diseases of early childhood, at least in this part of
the country.

Monads were found in two instances, while only once a
doubtful Ch. crystal was seen. Bucklers '■" states that Ch.
crystals were exceedingly seldom found in the passages of
children, and only present in eases of helminthiasis.

A limited number of stools,'" containing more or less
leucocytes and mostly red blood-corpuscles were examined
in regard to eosiuophile cells. In a few cases no eosinophiles
were seen, in most of the cases, few or relatively few were
present, while only in one case of a girl 1^ years old, few
well preserved eosinophile cells, but a great amount of free
eosinophile granules were present. Neutrophile elements
were very rare. The ages of the children varied between 6
months and six years. Loos'" mentions as a curiosity the
presence of numeroiis eosinophile cells in the passages of a
child suffering with follicular enteritis. In 16 of the 17
cases the neutrophile elements in the feces always exceeded
in number the eosinophile elements. This was particularly
evident in two cases with prolapsus recti.

The examination of the feces is to a certain degree unsatis-
factory. At times little material is obtainable with the rectal
tube, sometimes the passages contain but little suitable ma-
terial, and if much suitable material is available, it is hardly
possible to examine all and we must rely on samples. Thus
a true picture of the contents of the intestines is not always
obtainable.

In the case of Peter S., John P. and William K., Dr. Cole
was kind enough to make the agglutination test with bacillus
dysenterife Shiga, and obtained a negative result with a
dilution of 1:10. The bacteriological examination of the
feces, in John P.'s case made by Dr. Cole, did not bring out
any organism resembling the bacillus of Shiga. The method
of examination followed the suggestion of Flexner.'" From
15-20 plates, 25-30 cultures were taken in glucose agar and
those not producing gas were followed out. With 2 differ-
ent colonies of bacillus coli communis obtained from William
K., and not producing gas, the coiTesponding agglutination
test (1/10) was made with negative result.

Material taken from William K. was injected into the
rectum of cats in two instances, with negative results. But
these experiments were made under unfavorable conditions.

The examination was not made with the intention of
entering upon the question of the etiology of the dysentery,
since the newer investigations ©f Flexner ^ and particularly
Strong " — in whose papers the literature bearing upon this

question is thorouglily considered — confirm the views estab-
lished by Kurtulis, Councilman and Lafleur, Kruse and Pas-
quale and others assigning to amoebic dysentery a place as a
disease sui generis.

In the publications on amcebic dysentery little attention
was paid to the examination of the blood. Councilman and
Lafleur only speak of an anemia due to a deficiency in cor-
puscular elements and hemoglobin in about the same pro-
portion. Lewis'' found in a young man 17 years of age,
sick G months, 4,000,000 red and 31,000 white blood-cor-
puscles, Preston and Kurah "° in a colored man, 22 years old,
sick 2 months, 5,800,000 red and 5,600 white cells. Our
specimens for the differential count were prepared after a
method used by Dr. Ch. E. Simon for 18 months past. A
drop of blood is placed on a clean slide and spread with the
short, smooth edge of another slide, which is held at an angle
to the first and drawn off without applying force. To obtain
good results it is necessary that the whole procedure, from
the moment the blood appears, takes as little time as pos-
sible. Ewing gives a similar method and describes the ad-
vantages of the method of taking smears on slides. As a
staining medium the eosinate of methylene-blue proved satis-
factory. (A table giving the result of the blood examination
in each of the 5 cases will be found on the next page.)

In 4 of the cases there is a varying degree of anemia, which
finds its expression more in a deficiency in hemoglobin, than
in the red blood-coi"puscles. In all the cases, there is a
leucocytosis, in most of the coimts not a very high one.
Where the leucocytosis is more pronounced, the number of
the polynuclear neutrophile element is increa.sed. The sub-
division of the lymphocytes into small and large ones was
made on account of the striking appearance of the pro-
nounced large forms, but the differentiation of the less pro-
noimced forms from the small lymphocytes is frequently
so difficult, that it is more or less arbitrary. From cells
several times the size of an average red blood-corpuscle with
a large, rather faintly stained nucleus and relatively little
basophile protoplasm to the typical small lymphocyte all
forms of transition are seen. A round nucleus does not
belong to the characteristic qualities of these cells, as
Geissler and Tapha" state. The fact that the nucleus may
be karyolobic (see Pappenheim ") makes their ditt'eren-
tiation from other cells still more difficult. Frequently
little vacuoles were seen in the protoplasm. The pro-
toplasm looks sometimes rather uniform, in other instances
it makes the impression of a coarse network and again it
offers a more granular appearance. The amount of proto-
plasm is, as a rule, relatively small, but still somewhat greater
than in small lymphocytes, sometimes it is considerable. To
enter more closely upon this subject, this is not the place.
In tlie first count only the pronounced cells are registered
as large lymphocytes. In the subsequent counts the staining
properties of the nucleus and the amount of protoplasm
were taken into consideration besides the size. That these
cells which were first counted separately by Einhorn,"

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

361

Date.

1. Peter S.
X. 22. 1900

XI. 10

XI. 12

II. I'.i. lyoi

Hiemogl

IV. 1 1

Ward count.
X. 2(!. ISIOO
II. 22. 1901

3. John P.

X. 31. 1901..

XI. 8

XI. IS

XI. ."iO

60%

60%
55%
60«
67%

Red blood-
corpuscles.

4,800,000

4,800,000
3,900,000
5,200,000
4,480,000

White
blood-
corpuscles.

No. of
leucocy's
counted.

19,000

7,50

1037

20,000

1379

1.5,.500

1164

0,600

13.59

17,000

17,.500

Lymphocytes.

17.39
30. .5
30.03

20.9

13.6 %

( small 14.86 %
I large 2. .53 %
I small 10.33
I larjie 10.17
( small 4.03
j large 16.00
( small 3.45
'( large 17.45

£§Sa

7.8%
I 7.51
I 9.66

i • "

i 19.64

67.65S

66.22

63.11

60.6

51.54

o 3J

9.8«

7.91

7.27

9.28

7.43

0.95
0.48
0.86
0..51
0.51

14.54

1438

490

3396

5i%
6S%
55«

XII. 2...
Ward count.

XI. 11. 1900 I

I. 23. 1901 63«

3,200,000

3,600,000
4,000,000
4,200,000

4,940,000

18,000

13,000
10, .500

11,500

11,000
8,600

1000

19.S1

1351

1384

1486

548
306

q„ ., ( small 23.4

■'"•■■' \ large 3.8
.,.j small 16.14
-' ( large 5.59
2Q ^.,,3 small 14.08
( large 6.71
( small 1.5.67
\ large 11.14
) small 13.39
\ large 13.81

14.66
24.0

26.81
36.3

11.46

(•■■

jn.
f

17.31

13.13

19.04
20.0

59.5

1.9

1.4

343 1

59.53

2.77

0.15

4.19

....{

62 . 34

4.11

0.32

0.39

493 1

51,59

4.05

0.46

425 1

58 . 73

2.22

0.4

0.3

3.55

61.15

2.. 56

3.19

281

52.3

3.00

3.58

13 normoblasts.

3 megaloblasts.

9 normoblasts.

1 megaloblast.
No normoblast.
No megaloblast.
No normoblast.
No megaloblast.

1 normoblast.

3. William K.

I, 11, 1901

II. 21

50«
40«
85%

V. 2

Ward count.
III. 20 1 51%

5,000,000
5,000,000
5,000,000
6,.500,000

13,800
14,000
14,000
17,500

1557
2864
1397

36.84/
21.24^

38.96

small 9.25
large 17. .59
small 6.33
\ lame 14.92
( small 3.07
] large 36.89

ll3.01
i 5.58
I 15 . 39

57.8

71.43

50.35

3.01
1.81
5.08

0.51
0.06
0.85

415
2.53 i

711

For this difference
no reason could
be found.

4. Michael K
I. 9.01 5

III. 9.

40%

Ward count.

.| 45%

4,500,000
4,.500,000
4,500,000

37,000
17,000
27,600

1394
1596

.,„ „ ( small 7.96
I large 11.04

29.58 3 f^i"!' J^-l
( large ?3 s;

I 9.18

8.01

69.44
47.61

3.65
13.73

0.14
0

715
3334

5. Mary R.
III. 1. 01 68%

Ward count.
II. 31 [ 70%

5,400,000

34,300
17,740

1343

10.34

f small 0.48
I large 9.86

.36

80.64

0.16

0.4

are frequently found in tlie blood of children is well known,
and that the tyisieal small lymphocytes are sometimes rare
is mentioned particularly by Hock and Sehlesinger."

In regard to the number of eosinophile cells in the blood
of healthy children the figures of the different authors vary
much. Hock and Schlesinger find a variation from a few
hundred to several thousand in a cmm. during childhood.
The figures of Gundobin " and Weiss " are based upon
examinations of younger children. Canon," Fischl " and
Carstanjen *' do not give the actual leucocyte count, and
so these figures are not of much value to decide, if there
exists an eosinophilia or not. The average percentage of
the eosinophiles as given by Carstanjen for children from
2-3, 3-4, 4-5 and 5-6 years are 3.9^, 5.74,'?;, 6.3^, and 6.22,?^,
the last three the highest average figures during childhood.
The maximum figures for these periods are 6.2?^, 9.95^, 16.65,'i^
and 9.1;^'. Lappert's figures for 2 normal boys 5 years of age
are 3.97;^ and 8.8;^, the absolute figures being 361 and 660 in
the ccm.

Our cases Willi.im Iv. and Michael K., who left the obser-
vation without being cured, seem to show a tendency to in-

crease their relative and absolute eosinophiles. Mary K.
takes here too an exceptional standpoint in our series. The
figures of John P. show a slight decrease towards recovery,
while in the case of Peter S. a marked diminution of the
absolute number of the eosinophiles is shown. In this in-
stance we may be permitted to interpret the higher figures
prevailing during the disease as a slight degree of eosino-
philia associated with the disease [the anemia may have
exercised an influence upon the first figures].

The initial blood-picture of John P. very clearly demon-
strates the poor condition of tlie patient's general health.
In the first two examinations the red blood-corpuscles varied
very much in size, there was a slight poikilocytosis; a few
pronounced megalocytes and niicrocytes were present. Many
of the red blood-corpuscles were polychromatophilic, but
granular degeneration was never found. With the increase
in hemoglobin and in the red blood-corpuscles the blood-pic-
ture came nearer and nearer to the normal. The number of
blood-platelets seemed slightly increased at first, certainly
they were somewhat less numerous later on. As myelocytes
were counted all the mononuclear neutrojihile elements.

362

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

But particularly in the second count quite a number of these
cells did not exceed in size the usual polj'nuclear neutrophile
leucocytes. The nucleus was more centrally located, and
it resembled more that of the polynuclear neutrophile leuco-
cytes in its staining properties. All these characteristics sug-
gest that these cells do not belong to the typical myelocytes
of Ehrlieh, and it would, perhaps be better to follow the ex-
ample of Tuerk " and to designate these as mononuclear neu-
trophile leucocytes. The frequency of these cells decreased
rapidly, and on subsequent examinations they were only
occasionally found. In the first specimens a very large neu-
trophile leucocyte was seen, whose nucleus was divided into
four distinct, faintly stained parts. The body of the leuco-
cyte was connected by a small bridge with a small globule
apparently in the process of separation from the large cell.
The whole was filled with neutrophile granules. At sub-
sequent examinations of specimens of the same date one more
cell of this kind was found, but without the globule. Besides
this form, one cell was seen resembling the small neutro-
phile pseudolymphocyte of Ehrlieh, that is a small mononu-
clear neutrophile cell. The only difference was that the
nucleus did not take the stain very deeply, while the nucleus
of Ehrlich's form requires a great affinity for basic dyes.
The difference may be due to the different method of stain-
ing. Ehrlieh " found these forms in hemorrhagic small-pox
and in fresh pleuritic exudates. Eelatively frequently a
form was seen about 1| to 2 times the size of a typical small
lymphocyie, seldom larger, where the nucleus could hardly
or not at all be distinguished from the protoplasm. The
whole was more or less deeply stained and looked like a de-
ranged, rather coarse network.

The small number of red blood-corpuscles at admission,
the corresponding low percentage of hemaglobin, the poikil-
ocytosis and polyehromatophilia, the presence of normo-
blasts, megalocytes, megaloblasts and myelocytes indicate a
rather severe secondary anemia. The presence of myelocytes
in anemic conditions of children is not unusual, and Cabot."
who gives a short review of the cases, where they were found
in adults, comes to the conclusion, that their appearance has
perhaps the same significance, as the appearance of normo-
blasts.

The case of John P. may give rise to the suggestion that
the blood picture may assist to complete the clinical classifi-
cation of amoebic dysentery. In his case at least it falls
in very well with the other clinical picture.

The loss of blood does not seem to have been the only
factor in bringing about the anemia. Even if we consider
the frequent passages, he never lost as much blood as Peter
S. The hygienic surroundings of John P. did not differ
materially from that of the other children.

The number of our blood examinations is not sufficient to
allow definite conclusions. In one case, that of Mary R.,
an exceptionally low number of eosinophile cells in the blood
corresponds with the absence of Charcot-Leyden crystals
and with a small number of eosinophiles in the feces. This
would correspond with Biicklers' experience in helminthias-

is. In our series we can hardly say that strikingly high per-
centage of eosinophiles is associated with the presence of nu-
merous crystals. But it may be that our cases correspond
with those of Biicklers where a slight eosinophilia was found
by presence of many crj'stals, and subsequent examinations
may show that amoebic dysentery does not differ materially,
in regard to the crystals and eosinophile elements, from
helminthiasis. The only one of our cases which shows a
distinct, if slight, eosinophilia is that of Peter S., while the
figures of Michael K. are at least suggestive.

One circumstance certainly deserves attention. If in the
passages of a child — at least in this part of the country —
Charcot-Leyden crystals are found, we have to take into
consideration the possibility of amoebic dysentery, a fact
which it will be well to remember, since the amcebse them-
selves may only be found after repeated examinations.
What the significance of the eosinophile cells is remains to
be seen. Their numerical relation to the neutrophile ele-
ments may perhaps be of some value.

I will add a short history of another case, which could not
be fully considered, because the patient did not come under
treatment.

Katie N., 8 years of age, white, living in Baltimore, came
to the dispensary on September 9, 1901. She complained
of chills and fever and dian-hoea. She has had diarrhoea
for a long time, passing mucus and sometimes blood with
much pain and tenesmus. Besides she has much pain in
lower abdomen. Present illness began 5 days ago with
shaking chills followed by fever, in which she is delirious.
She has had a chill every day since at about the same time.
No more bleeding. The child was rather pale and thin.
Heart and lungs were clear. The spleen is enlarged and the
abdomen is rather tender on pressure. Eose-spots. Tem-
perature 100.1°. No Plasmodia malarias were found in the
blood. The feces (rectal tube) looked very typhoidal. At the
microscopical examination no Charcot-Leyden crystals and no
monads were seen; there were vei7 few cellular elements. In
nearly every specimen one or more motile amoebae were found,
but none of them contained red blood corpuscles.

It is very probable that in this case a typhoid fever (?)
superposed itself upon an existing amoebic dysentery, but the
examination is not sufficient to make a definite diagnosis.

Note. — AVhile this paper was in print a white boy, 2 years
8 months of age, of Polish descent, was brought to the dis-
jjensary suffering with loss of appetite, vomiting and very
frequent bloody passages associated with pain. The people
live in the southeastern part of the city. The present illness
has lasted 12 days. The boy was very weak, the jjulse quick
and small, the temperature 100.8°. The rectal tube brought
a small amount of bloody mucoid material with a very offen-
sive odor. Numerous motile amtcbae containing red blood-
corpuscles were seen under the microscope. A few monads
were present and bismuthsulphide crystals, but no Charcot-
Leyden. His death prevented further examinations. An
autopsy was not permitted.

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

363

BiBLIOGHAPHT.

1. American Journal for the Mod. Sciences, 1898, vol. cxv.

2. Med. and Surgical ReiJorts of the Boston City Hospital,
1898.

3. Virginia Med. Monthly, October, 1895.

4. Nothnagel's Collection, vol.' v. Kurtulis Dysentery.

5. Die Protozoen als Kraukheitserreger. Jena, 1891.
G. Eef. in Loesch's Paper, Vireliow's Archiv, vol. l.xv.

7. Centralblatt fiir Bacteriologie, vol. x.

8. In Mosler und Peiper, Xothnagel's Collection, vol. vi.

9. Deutsche med. Wochenschrift, 1891, p. 853.

10. Deutsche nied. Wochenschrift, 1900, p. 515.

11. Johns Hopkins Hospital Reports, vol. ii.

12. Traite des maladies de I'enfance, Grancher, vol. iii.

13. These de Paris, 1892. Diagnostic et traitment des
abces du foie.

14. Lancet, 1887, ii, 310.

15. Indian Med. Eecord. Calcutta, 1892, iii, 7.

16. British Guiana Med. Annal. and Hospital Eeports,
Dcmerara, 1892, p. 173.

17. Indian Med. Gazette, Calcutta, 1890.

18. Gazette des hopit., 1894. Proust.

19. Ceylon Med. Journal, Colombo, 1887-88, i, 29.

20. Transactions of Am. Surg. Soc, vol. xv, p. 240, case xi.

21. Pediatria Xapoli, 189(3, iv, 340.

22. Virchow's Archiv, vol. clvii.

23. Zeitsclirift fiir Hygiene, vol. xvi, 1894.

24. Zeitschrift fiir klin. Medicin, vol. xl, p. 59.

25. Centralblatt fiir iiathol. Anat., Ziegler-Kahlden, 1899,
vol. .X. p. 940.

26. Johns Hopkins Hospital Bulletin, 1897.

27. Die Faeces des Menschen im normalen und pathol.
Zustande, etc. Berlin, Hirschwald, 1901, p. 91.

28. Philadelphia Med. Journal, 1898, p. 1076.

29. Clinical Pathology of the Blood, 1901, p. 140. N. B.
Bucklers does not mention eosinophilo cells in the feces.

30. Lyon medicate, 1897, Ixxxvi, p. 421.

31. These de Lyon, 1900. Des abces dysent. tardifs du
foie et du poumon.

32. Miinchner med. Wochenschrift, 1898, p. 41.

33. Maryland Med. Journal, 1900, p. 197.

34. Miinchner med. Wochenschrift, 1894, p. 21.

35. Jahrbuch fiir Kinderheilkunde, vol. xxxi.x, p. 345.

36. Johns Hopkins Hospital Bulletin, 1900, p. 231.

37. Report of the Surgeon-General of the Army, 1900,
Strong and Musgrave, p. 251; and Strong, Circulars on Tropi-
cal Diseases, No. 2, 1901.

38. Maryland Med. Journal, 1896, p. 145.

39. New York Med. Journal, 1894, ii, p. 593.

40. Jahrbuch fiir Kinderheilkunde, 1901, p. 630.

41. Virchow's Archiv, vols, clix and clx.

42. Inaug. Dissertation, Berlin, 1884. Ueber das Ver-
halten des Lymphocyten zu den weissen Blutkorperchen.

43. Beitrage zur Kinderheilkunde, etc. Kassowitz, 1892.
Nim Folge, ii.

44-45. Jahrbuch fiir Kinderheilkunde, vol. xxxv, 1893, pp.
187 and 146.

46. Deutsche med. Wochenschrift, 1892, p. 206.

47. Zeitschrift fiir Heilkunde, 1892, p. 277.

48. Jahrbuch fiir Kinderheilkunde, 1900.

49. Zeitschrift fiir klin. Medicin, vol. xxiii, 1893, p. 244.

50. Klin. Untersuchungen iiber das Verhalten des Blutes
bein acuten Infections Krankheiten. Wein und Leipzig, 1898.

51. Nothnagel's Collection, vol. viii. Die Anemie, p. 52.

52. A Guide to the Clinical Examination of the Blood,
1897.

THE ADVANCES MADE IN MEDICAL AND SURGICAL DIAGNOSIS BY THE RONTGEN METHOD.'

By Charles Lester Leonard, A. M., M. D., of Philadelphia.

The Rontgen method of diagnosis is the result of an
evolution which followed the discovery of a new form of phy-
sical energy, possessing the peculiar property of penetrating
and producing shadow pictures of the otherwise invisible
portions of the body.

The development of this method of picture making, into a
method of physical diagnosis, was necessary to its employ-
ment in medicine and surgery. It was necessary to apply
accurately, with precise methods, its power to obtain mechani-
cally data upon which a diagnosis can be based.

Like all other diagnoses a Eontgen diagnosis must be
based upon normal and pathological anatomy combined with
X-ray technique and clinical experience. A medical educa-
tion is therefore a prerequisite to its accurate application in
diagnosis.

'Read before tbe .Johns Hopkins Hospitiil Medical Society, M.Trcli IS,
1901.

The observer must possess the knowledge of what to look
for, as well as how to look, and in addition he must be able
to interpret what he sees. The Eontgen diagnostician must
acquire by clinical experience the ability to obtain and in-
terpret correctly the data upon which he bases his diagnosis.
This is the personal element in this otherwise mechanical
method. It can be eliminated to a great extent, since the
data are mechanically registered and hence can be studied
by different observers and compared with the normal and
pathological findings in similar cases.

The futility of attempting to utilize the data obtained by
this method without accurate knowledge of the exact process
by which they were olitained has often been demonstrated.
Such attempts have led many surgeons into errors, and go a
long way toward making up the sum of those cases in wiiich
this method of diagnosis has been said (o Ite at fault. Un-
doubtedly the most experienced may err, but the errors are

364

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 139.

not due to the means employed to make the diagnosis, they
are the result of improper use in the methods of employing it,
and of erroneous interpretations. Clinical experience has
demonstrated the accuracy of this method when correctly
employed. The mechanical element in this diagnosis assures
its accuracy. Data can be obtained that can be compared
with mechanically recorded normals. It is this element that
gives the clinical thermometer its value. It has determined
the normal temperature and its physiological variations, and
measures mechanically pathological variations from that
standard. Even this simple instrument in diagnosis must be
employed and read correctly.

In a technique capable of employing this method in physi-
cal diagnosis, is included a knowledge of the varying qiialities
of the Rontgen ray, and of the method of employing in each
case the particular quality required to secure the desired data.
This variation is necessary for different purposes and for the
examination of different parts of the same individual. In
the more difficult diagnoses, where more delicate differentia-
tions are required, the quality of Rontgen discharge must be
adapted to the individual case.

In many cases this method of diagnosis should be employed
primarily, as in locating foreign bodies and in the diagnosis
of fractures. Here the resiilts are more accurate and com-
prehensive than can be obtained by other methods, while the
dangers from infection, additional trauma, and devitalization
of tissue are avoided. In other cases the best results can be
obtained by employing this method to differentiate second-
arily between possible diagnoses. Again, its only use may
be to confirm, in a measure, a previously formed diagnosis.

The Rontgen method of diagnosis has as yet limitations in
its application. In certain directions an absolute positive
or negative diagnosis can be rendered. In others it aids.
While it is as yet absolutely without value in other cases
where its future development may render it of the first im-
portance.

I shall touch upon only a few fields in diagnosis where the
advance made is most clearly illustrated.

Although the advance in the diagnosis of fractures has been
very marked, and of the utmost value in directing treatment,
there are few surgeons who have fully realized, appreciated,
and used this method to its full extent. One of the principal
advantages of this method is that without producing pain it
seciires more absolute and accurate knowledge than the older
methods, and does not produce any further trauma or en-
danger neighboring structures. Pain is nature's signal of
injury to tissue. The ansesthetic hides it, yet the injury
inflicted during manipulations and examinations must be
considerable. The reparative process is delayed in proportion
to the amount of trauma inflicted. The production of pre-
ternatural mobility and crepitus must frequently destroy con-
necting bands of periosteum, produce fragments, and in-
crease oozing. Our knowledge of reparative processes teaches,
that these elements are detrimental to rapid union and that
they must be absorbed before union can take place. In im-

pacted fractures a diagnosis established in any other way
serioTisly increases the severity of the injui-y.

The accuracy and detail which this method furnishes are of
great value in directing treatment. An undetected commi-
nution delays repair and frequently results in non-union.
The callus thrown out from a linear fracture that enters a
joint, or an undetected interscapular fracture will injure the
functions of the joint unless the proper course of treatment
is pursued. The shape and position of the line of fracture
direct attention to the difficulties and complications that may
attend the treatment, and help in avoiding them. This
knowledge also aids in reducing the fragments and securing
exact coaptation. The success of attempts at reduction and
the value of the fixation apparatus are readily determined.
The accompanying illustrations point out the value of this
method in detecting rare fractures, and illustrate its accuracy
in determining the presence of interscapular fractures that
would otherwise escape detection.

The treatment of fractures by open operation is a well
established practice and a marked advance. The Rontgen
method of diagnosis forms the basis for the division of frac-
tures into those that demand operation and those that can
be properly reduced and treated by the older methods.
A^Tiere the skiagraph shows that proper reduction cannot be
secured or that the fragments cannot be maintained in cor-
rect apposition by ordinary fixation apparatus, the patient
should have the facts, including the skiagraph, fully ex-
plained to him, and should be given his choice between im-
perfect union and operation.

The accuracy which has been attained by this method of
diagnosis is such, that, although there are still certain por-
tions of the skeleton where fractures cannot be excluded, yet,
where a skiagraph can be obtained, having sufficient defini-
tion to justify a negative diagnosis, the patient should not be
treated as if he had a fi-acture. All fractures of the limbs
can now be readily excluded. Before the development of
this accurate method it was good surgery to treat suspected
fractures as if a fracture existed. To-day, such a course can
only be justified by the inability to have a Rontgen examina-
tion made.

The exact determination of congenital osseous malforma-
tions and defects by this method of examination has aided
materially in establishing diagnoses before orthopedic oper-
ations, and helped the operator to plan the intervention be-
fore the actual operation is undertaken. It has done much in
differentiating between the various forms of congenital dis-
locations and malformations of the hip joints, a condition
which one of the accompanying skiagraphs illustrates.

The application of the Rontgen method to the diagnosis of
renal and ureteral calculi has supplied a deficiency in surgical
diagnosis. The kidneys are anatomically situated in a posi-
tion of the greatest safety. They are, however, for that
reason, difficult to reach by ordinary methods of physical
diagnosis. They are also surroimded by other viscera whose
pathological lesions present a symptom-complex that it is
often impossible to differentiate from renal disease except by

THE JOHNS HOPKINS HOSPITAL BULLETIN, DECEMBER, 1901.

PLATE XL.

Fig. 1. — Normal fiiot.

Fig. 2. — Diastasis of perios-
teal scale at the attacbment of
the teudo Achillis, the result of
muscular strain.

Fig, 8. — Multijile reual aud ureteral calculi.

Fig. .5. — Separation of symphysis pubis.

Fig. 9. — Ureteral calculus, just above sacrum.

Fig. 6. — Congenital dislocation of both hips.

Fig. S. — Fracture of iutcrual malleolus.

Fig. 4. — Ankylosis of knee, resulting from
rheumatoid arthritis.

Fig. 7. — Calculi in left aud right kidneys.

Fig. 10. — Phleboliths in veins of broad ligaments.

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

365

exploratory operation. When, however, the diagnosis has
been reduced to one ot peri- or intra-nephritic conditions
the problem still remains a very diiiicult one.

This method has therefore many atlvautages, since it is
possible by its use to absolutely exclude or detect all calculi.
Other renal conditions justify exploratory operations, but no
other condition justifies incision into an apparently healthy
kidney. Where calculi have been excluded by this method,
incision into the kidney during an exploratory operation can
only be justified by the presence of macroscopic pathological
conditions.

Double exploratory nephrotomy has been suggested as a
method of determining the presence of calculi in the second
kidney where the destruction of one kidney by an abscess,
the result of calculous nejihritis, demands a nephrectomy.
By this method the presence of calculi in both kidneys can
be determined before operation and the proper procedure
decided upon. The exclusion of calculi from the kidneys
and ureters removes this source of danger as a complication
of any operative intervention that may be necessary upon the
other kidney or ureter.

Early operation in cases of calculous nephritis and ureter-
itis is of great importance. Statistics show that the gravity
of any operative procedure increases with the length of time
the calculus has been in the kidney, but more especially by
the presence of infection. A calculus in a kidney invites
infection. Early detection and removal are therefore very
advantageous.

There are, however, graver reasons than these for early
diagnosis and removal. These small calculi are not only a
menace to the structure of the kidney, but also to its func-
tion. Those that produce the fewest symptoms often give
rise to the most serious condition. Calculous anuria from
the impaction of one of these small calculi in the ureter and
its occlusion, menaces the life of the patient as well as the
integrity of the kidney involved. If the other kidney is
unable to carry on the function for both, it often ceases to
act, a complete anuria follows and the patient dies. The
other kidney may already be the seat of calculous disease, or
its ureter may have been occluded at some former time and
its fimction destroyed.

These are the dangers that threaten the patient who has
an unsuspected or an undetected calculus. The Eontgen
method detects suspected calculi and permits early operation.
It changes a condition of indefinite danger into a condition
that is safe and amenable to immediate operation if it is

necessary. It makes the non-operative treatment of cases
suspected of calculus rational, because the position of the
calculus is known or all calculi are excluded.

It has made an expectant non-operative treatment rational
in certain cases where calculi are found in the pelvic ureters,
and the symptoms point to recent progression down the
ureter and the preservation of full renal function. In cases
of complete anuria it directs operation immediately to the
calculus, if that be its cause. The information secured by
this method is very comprehensive and renders every opera-
tion complete. It limits operation to the exact seat of the
calculi. It is no longer necessary to open and explore the
hydronephrotic kidney to find as its cause a calculus in the
pelvic portion of the ureter. The operation is limited to the
removal of the calculus. The exact as well as the general
position of calculi and their number are shown in the skia-
graph.

Thus a calculus in one pole or calyx of the kidney can be
removed through a small incision without the necessity for
further exploration. Operation based upon the Rontgen
diagnosis must be complete, as the number of calculi are
known and their presence or absence in the other kidney or
ureter has been ascertained.

This summary of the advance made by the Eontgen method
of diagnosis in the detection of renal and vireteral calculi and
their exclusion, is based upon the examination of 163 sus-
pected cases and the detection of calculi in 47.

A further proof of the actual advance, is the need for the
revision in our ideas of the relative frequency of renal and
ureteral calculi. Eenal calculi have been supposed to occur
the most frequently. The results of this method of examin-
ation show that of 47 cases in which calculi were detected,
in 27 the calculi were found in the ureter.

The minuteness of the calculi that can be detected is shown
by the passage of calculi in five cases in which each weighed
less than one grain. The minute detail obtainable is render-
ed evident by the detection recently of phleboliths, which in
a measure complicated the diagnosis. In one case a calculus
was found, which examination showed was a phlebolith in
the vaginal wall. In a second case six phleboliths were found
in the venous plexus of the broad ligament, as was demon-
strated by a subsequent coeliotomy.

Note. — As much of the detail is lost in the process of
reproduction the positions of the calculi have been designated
by dots. • !

THE JOHNS HOPKINS HOSPITAL BULLETIN.

Volume XII closes with this number. The subscription price is $1.00 per year. The set of twelve volumes will be sold for

$23.00.

366

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 139.

rATHOLOGlCAL REPORT UPON

A FATAL CASE OF ENTERITIS Wmi ANEMIA CAUSED M
UNCINARIA DUODENALIS/

By John L. Yates, M. D.,
Assistant in Pathohgy, Johns Hopkins University.

The case here reported is the first published occurreuce of
the disease in Maryland. During this year eight unmistakable
cases have been reported in this country, a number equal to
all of those heretofore on record where the diagnosis is
indisputable.

That many individuals harboring Uncinaria duodenalis
liave not had their affection diagnosed there is no doubt, and
its prevalence in this country is certainly gi-eater than has
been supposed. Being endemic, as it is in Porto Eico and
the Philippines, the importance of an early recognition will
be even greater.

Tlie appended list of cases reported from the United States
shows that the disease is not localized in the South and dem-
onstrates how easily contamination may be spread, five of the
sixteen positive cases liaving contracted the disease in this
country.

The patient who is the subject of this report was admitted
to the medical department of the Bay View Asylum, October
2, 1901, and came under the care of Dr. E. Lee Hall,^ to
whom I am indebted for notes on the clinical history and
for the privilege of examining the dried-blood preparations
which he made upon two occasions. The history of the case
is as follows:

J. 0"E., English sailor, aged 39 years.

The past history developed nothing of importance. It
was not clear where the disease had been contracted. His
only known stop at a tropical port (Vera Cruz, Mexico), was
immediately before his aiTival in Baltimore and after the
onset of his symptoms.

He had been feeling badly for six months, his appetite and
digestion were poor, and colicky abdominal pains were pres-
ent with some diarrhea. No cough nor night sweats were
noticed, but there had been some dyspnea. About four weeks
before his admission he had become decidedly worse. There
had been a noticeable loss in weight, the diarrhea and ab-
dominal pains had increased and blood had appeared in the
stools. The dyspnea increased.

At the time of entrance to the Asylum nothing of im-
portance was revealed by physical examination aside from a
rather pronounced anemia with poor general condition and
a noticeably dulled mentality. The area of cardiac dullness
was not increased, an inconstant hemic murmur was noted at

'Stiles: Texas Medical News, July, 1001, p. .523. The priority of
Uncinaria to Ancliylostoma as the name of the genus is pointed out and
its employment therefore positively indicated.

^T>r. Hall has made a clinical report of the case which was published
in The Journal of the American Medical Association, November 30, 1900
p. 146i.

the apex. There were some points of localized abdominal
tenderness. The specific gravity of the urine was 1010; no
albumin nor casts were present.

On the 9th day after admission a blood count made by Dr.
Hall showed the following conditions:

Red blood-corpuscles 3,500,000

White " " 34,000

Hemoglobin was not estimated.

Eosinophiles^ about 35.^

No normoblasts were seen.

The anemia became more and more profound, and on the
17th day another blood count showed:

Red blood-corpuscles 800,000 (lfi(g)

White " " 39,600

Hemoglobin lli^

Eosinophiles about S^

Normoblasts weie present but not abund-
ant 0.8<^

The jjatient's general condition grew gradually but progres-
sively worse from the time of his admission. There was no
extensive hemorrhage from the bowels. The stools were
fairly frequent and tarry in character. Abdominal pains
persisted.

On the 18th day he had become very much worse, the res-
piration and pulse gradually grew weaker and he died quietly
at 7.30 P. M. At a necropsy done 18 hours later the following
conditions were found:

Body. — The body, 173 cm. long, was emaciated and very
pale, the skin had a peculiar yellowish tint. The conjunctivae
and mucous membranes were extremely anemic. Slight rigor
mortis was present. The peritoneal cavity contained no excess
of fluid, the serous surfaces were smooth and free from ad-
hesions. The upper portion of small intestines was moder-
ately contracted and somewhat whitish. In the cecum and
large intestine, which were rather distended and very trans-
lucent, were scattered black foci that suggested ecchymotic
patches in the intestinal wall, but proved to be bits of fecal
matter adherent to the mucous surface.

Thoriur. — The pleural cavities contained pale, slightly turbid
fluid in moderate amount. There were a few adhesions on
the right side. On the left side very soft, white and edema-
tous adhesions were general except along the posterior aspect.

Pericardial cavity contained a small amount of similar
fluid. Both serous surfaces were smooth and shiny.

■iThc differential counts were little more than approximate as the
specimens stained poorly. The eosinophiles were, however, easily
recognized and that proportion is fairly accurate.

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

367

Heart was very slightly enlarged, weighing 370 grammes.
The contained blood was very jiale and watery. The two
sides were partially filled with a continuous tenacious clot,
colorless and translucent. The valves were apparently nor-
mal. The myocardium, which was very pale and soft, con-
tained a few opaque areas. The aorta showed but very slight
changes.

Iaukjs. — Both lungs were voluminous and everywhere crep-
itant. The left lung was covered with the hairy white
adhesions above described. Both showed on cut section con-
siderable pigmentation and very pronounced pallor with a
greatly increased juiciness of the dependent portions, par-
ticularly on the left side. The bronchi, filled with pinkish
frothy material, were not injected.

Spleen. — The capsule was wrinkled, pulp was very soft, pale
and friable. The Malpighian bodies were easily recognized.
The organ weighed 100 grammes.

The liver was not enlarged. Surface was smooth and on
it were very striking, white bloodless lines, appearing like in-
testinal lymphatics filled with chyle. The cut surface was
of a light yellowish-brown color. The lobules were not defi-
nitely made out. The weight was 1350 grammes.

Kidneys. — The capsules were very slightly adherent; stel-
late veins not injected. The cut section showed the cortex
to be somewhat cloudy and the cortical strife were not recog-
nized; the glomeruli were visible.

Bladder was distended with pale, clear urine; the mucosa
was perfectly smooth and dead white in color.

Stomach contained much tenacious mucus mixed with coffee-
groimd-like material. The mucosa was very pale.

Duodenum. — Passing downward, at a point corresponding
to the 3d portion, hemorrhagic contents were first encoun-
tered, and in this material a few adult uncinaria were found.

Jejunum and Ileum. — The mucoid nature of the contents
persisted from the stomach to the cecum, but this material
was blood-stained throughout. The mucosa was everywhere
pale, the more prominent portions like the edges of the val-
vulae conniventes were slightly injected. No ulcerations were
noticed.

The worms, which were present in large numbers (probably
thousands), were in a living condition and many were found
with their head ends buried in the mucosa. These were
quite firmly attached and were only separated with some force;
there was left behind a sharp punched -out hole similar to a
pin prick, with a reddish base and a slightly raised margin.
No surrounding halo of injection was recognized. The amount
of the muco-hemorrhagic material was greatest where the
worms were most numerous. The process was apparently
more advanced in the lower jejunum and in the ileum than
in the duodenum. No parasites were observed in the last
few centimeters of the ileum and at the ileo-cecal valve the
contents changed in character.

Large intestine was filled with scybalous tarry feces and no
parasites were observed. No ulceration was noted, though
the rectum and sigmoid flexure were somewhat injected.

Brain was extremely anemic in appearance, but was other-
wise apparently normal.

A detailed description of the parasites and ova will not be
given. There was no difficulty in their identification, as the
conditions found agreed absolutely with the accepted descrip-
tions of the parasites. .The female nematoid worms were 8 to
10 mm. long and showed at one extremity a buccal cavity
armed with booklets. The other extremity was conical. They
contained ova and red blood-corpuscles. The male parasites,
which were decidedly smaller (0.5 cm. long) also contained
red blood-corpuscles, and at the tail end had the expanded
Ijursa copulatrix.

The ova, which were ovoid in shape, contained a granular
central portion surrounded by a narrow capsule of clear trans-
lucent material. No attempt was made to estimate the prob-
a1jle number of parasites present nor the relative frequency
of the sexes, though it appeared that the females exceeded the
males by a greater ratio than that usually mentioned (4 to 1).
All the females examined contained ova, and these ova were
found in the greatest profusion in the large and small bowel.
Specimens of the intestinal contents also contained a great
many Charcot-Leyden crystals.

In certain of the ova from the intestine segmentation had
begun. By keeping some of the intestinal contents moistened
and at a moderate temperature (about 28° to 29° C.) develop-
ment of the ova into rhabditiform embryos was observed.

Microscopic Examination of Tissues.

Lungs showed considerable coal pigmentation and edema.

Spleen. — The Malpighian bodies are small in proportion to
the jDulp. The striking peculiarity of the latter was the
presence of eosinophiles in great number, as many as adozen
often appearing in one field of the oil-immersion lens (Zeiss,
ocul. No. 1, object. 1/12). They were slightly larger than
the polymorphonuclear leucocytes and the nucleus was rarely
round or horseshoe-shaped, but more often was bilobed or
trilobed. The nucleus usually had a vesicular appearance,
but in a much smaller proportion stained deeply and homo-
geneously. No evidence of nuclear segmentation was recog-
nized. No nucleated red blood-corpuscles were seen.

Liver. — The changes in the liver were very widespread and
striking. In the specimen examined each lobule contained an
area of necrosis, invariably located about the central vein.
The size of these foci varied from a few cells about the vein
in some instances to an extent involving one-third or even
half the distance to the periphery of the lobule in others.
The outline of the necrotic areas was irregular but fairly sharp.
In them the nuclei of the liver cells remained imstained and
tlie protoplasm stained deeply in eosin. The transition from
the living liver cells was quite sudden, karyolysis rather than
karyorrhcxis having occurred. Red blood-corpuscles were fre-
quent about the necrotic cells and, unlike those in the capil-
laries elsewhere, stained deeply with eosin. There was also
a limited infiltration with polj-morphonuclear leucocytes and
the endothelial cells of the capillaries had appai-ently under-
gone some proliferation. The wall of the central vein had a
hyaline appearance but the nuclei of the intima were recog-
nizable. In the necrotic areas, especially in the smaller less

368

JOHNS HOPKINS HOSPITAL BULLETIN.

[1^0. 129.

advanced foci, were frequent deposits of a bright yellow pig-
ment which was refractile and granulai-. This occurred in
and about the cells and was not obsei-ved in the peripheral
portion of the lobule where the cells were well preserved.
The condition presented in the liver was the form of central
necrosis described by Mallory (1).

Kidneys. — Scattered in the cortex, usually below the cap-
sule, were a few small foci showing an increase in connective
tissue with destruction of renal elements, the glomeruli under-
going hyaline degeneration, and a few of the tubules being
atrophic and containing hyaline casts. The epithelial cells
were very granular in appearance.

IniesHne. — The intestinal contents were made up of altered
blood, mucus, bits of mucosa, cells which are more or less
degenerated and numerous ova, Chareot-Leyden crystals and
swarms of microorganisms. Here and there were sections of
the parasites, but in no place was the cephalic extremity found
in close relationship to the mucosa.

In some specimens the mucosa was everywhere partially, and
in some foci completely, necrotic in appearance. Not an
intact villus was found, and even the glands of Licberkiihn
were not completely preserved. It was difficult to make out
the extent of the ante-mortem destruction of the mucosa.
In other instances the preservation of the tissue was such that
but slight ante-mortem destruction seemed probable. The
basal part of the mucosa was infiltrated with eosinophiles in
enormous numbers, so closely packed together that seventy-
five were counted in one field of the oil-immersion. They
were essentially of the type described in the spleen and
appeared to have replaced the lymphoid elements which are
normally present in such large numbers. There was an
induration of the tissue with fibroblastic cells. In the sub-
mucosa eosinophiles were present in almost equally great num-
bers, occurring packed together in groups and rows between
the fibrous tissue strands. Eosinophilic cells were found in
small numbers within the interstitial tissue of the circular
muscular coat but less frequently in the longitudinal coat.
A few were present beneath the serosa. They were also seen
to have penetrated the glandular structures and were found
between the epithelial cells and in the lumina of the glands.
No eosinophilic cells were found with signs of nuclear di-
vision. The nuclei of certain of these eosinophiles were
seen to stain deeply and homogeneously, the eosinophilic
granules becoming somewhat pale and less distinct. The
nuclei in this instance took on a much more polymorphous
form, finally undergoing fragmentation into numerous small
particles. In a few cells with fragmented nuclei tlie
granules were still to be recognized, where as a rule only a
faint pink homogeneous cell-body was visible. Since this
fragmentation was most marked nearer to the mucosa and in
the points of greatest infiltration and was present to a com-
paratively slight extent in the spleen it was probably the
result of a degeneration caused by the action of some toxic
substance.

Anatomical diagnosis. — CataiThal gastro-entcritis with
hemorrhage caused by Uncinaria duodenalis, anemia, effusion

in pleural and pericardial cavities, edema of the lungs, fibrin-
ous pleurisy, dilatation and hypertrophy of the heart (slight),
central necrosis of the liver, chronic interstitial nephritis
(slight).

Scheube (2) in his work on tropical diseases gives an account
of the post-mortem conditions commonly found in uncinari-
asis. There may or may not be emaciation associated with
anemia, the heart is often slightly hypertrojjhied, the myo-
cardium is soft and fatty. The liver and kidneys but seldom
amyloid, are usually fatty; the stomach presents a chronic
catarrhal condition at times with considerable dilatation,
the mucosa of the ileum and jejunum contains numerous
small petechiae, dark red if recent or slate colored if old.
In cases of recent development the mucosa may be covered
vnth fresh blood, but this is uncommon where the disease is
of long standing, even in the presence of numerous parasites.
Parasites are often found attached at the center of the
petechiffi or a break in the mucosa may indicate a point of
previous attachment. Hemorrhages of considerable extent
may occur into the submucosa, and Billiarz and Grassi are
c^uoted as having found parasites in the submucosa rolled up
and surrounded by such collections of blood. Sandwith,
however, found parasites upon several occasions with a half
of their body buried in the submucosa. From this it is
supposed that Bilharz"s and Grassi's observations are to be
explained by the activity of the worm in penetrating the
mucosa rather than as an intracorporeal development of
the embryo.

The intestinal mucosa may be thickened and the solitary
follicles, Peyers patches and mesenteric glands enlarged.
There is said to be very profound anemia of the brain.
Wucherer has reported a case of adhesive peritonitis associated
with the presence of uncinaria in the intestine. Marius and
Francete state that the bone-marrow is in a condition similar
to that seen in pernicious anemia.

Williams (3) observed a perforation high in the small intes-
tine at the site of an old cicatrix and a number of round scars
in duodenum and jejunum suggesting ulcerations.

Fearnside (4) in necropsies on 78 cadavers containing
uncinaria found that GO per cent showed in the mucosa areas
of congestion several centimeters in diameter and 11 per cent
had small erosions and ulcerations 1-2 mm. in diameter.

Strong (5) in a case showing at necropsy a large number of
parasites describes in sections from the small intestine an
eosinophilic infiltration of the mucosa of the miiscularis
mucosa; and part of the submucosa. Certain of these eosino-
philes are increased in size, and contain large red swollen
granules of a vesicular appearance. Breaks in the mucosa
extending downward to the submucosa were found. These
were surrounded by areas of leucocytic infiltration and hemor-
rhages and were supposed to be caused by the parasites, though
none were foiind in the section examined.

The changes in the blood and the factors in the causation
of these changes are of very great interest and practical value.
It has been held that the anemia is due merely to the abstrac-

Decembek, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

369

tion of the blood from the intestine by the parasites. Against
this may be urged the fact that the anemia does not always
vary directly with the number of uncinaria present in the
intestine. Cases of profound anemia with a comparatively
small number of parasites are on record. Besides this there is
evidence that there is an absorption of some toxic substance.
The existence of a deposit of blood pigment in the liver is in
favor of some hemolytic agent being present, as is the occur-
rence of necrosis there an indication of an actively toxic
agent. MaUory (Ij has been able to produce experimentally
the form of necrosis present in this case, a necrosis limited
to the centre of the lobules, and he thinks this variety rather
than the irregularly disseminated foci of smaller size repre-
sents the action of a toxine. Eake (6) has demonstrated in
five cases of uncinariasis that the amount of iron present in
the liver post-mortem is less (about 1/7) than that found in
pernicious anemia. However, there is a considerable quantity
of blood lost to the body and this talven with the low color
iadex seen in uncinaria cases would seem to olfer sufficient
explanation for such results. Koger (7) points out that this
color index is about ^. Ashford's (8) counts made from 19
Porto Kican cases give an average color index of about 6/10.
In the most severe types the conditions of a primary anemia
are simulated.

Calamida (iij has shown that an extract made from the body
of certain tape-worms obtaiaed from dogs is capable of pro-
ducing death in dogs and guinea-pigs by iutoxication with
fatty degeneration of the liver when injected into circulation
or directly into the liver. This extract (iu normal saline so-
lution) has a dethiite hemolytic action on the red corpuscles
in test tubes kept at 37°. Nucleated red corpuscles appeal'
in the peripheral circulation should the animal survive after
inoculation with this material, and also a leucocytosis is pro-
duced ia which the eosinophiles predominate.

The association of an eosinophilia with intestinal parasites
in man has been observed for several species by liiicklei's (10)
(Uncinaria, AnguHlula, Tinea saginata. Tinea solium, As-
carides, Oxyuris), but whether there is a chai'acteristic leuco-
cytosis in uncinariasis or not is not cei-tain. According to
Lutz (11) there is none, but this writer thinks that later in
the course of the disease there is a relative increase in the
number of the white cells, though actually there is a reduction.
Koger (7) gives l-bM as the ratio of white to red cells. In
Ashford's (8) 19 cases a leucocytosis of over 10,000 was present
in but two, the number was below 5000 in four, while the
average of white to red cells was about 1-290. In the pub-
lished blood-counts there is no apparent relationship be-
tween the anemia and the leucocytosis, and a high leucocyte
count is present in perhaps less than one-half the cases.

The causation of the eosinophilia is open to a fairly satis-
factory explanation. The presence of intestinal parasites in
man (and animals) is frequently accompanied by an increase
in the eosinophiles of the blood and this increase is caused
by many forms of parasites. It was first obsei-ved in indi-
viduals harboring uncinaiia by Miiller and Rieder (12) in
1891. Later Zappert (13) observed in association with eosino-

philia, the presence of Charcot-Leyden crystals in the stools
of two individuals infected with uncinaria.

Bucklers' (10) investigation of the relative frequency of
eosinophiles and Charcot-Leyden crystals in the stools of
persons suffering from intestinal parasites apparently estab-
lished a definite relationship of the one to the other, and it
was found that after the administration of an anthelmintic
the persistence of Charcot-Leyden crystals in the stools indi-
cated that the parasites had been incompletely removed.

Leichtenstern (14) found in a fatal case of uncinariasis that
in these parts of the intestine where the worms were the most
numerous were to be found the largest number of Charcot-
Leyden crystals. Biicklers (10) advanced the theory that the
crystals were an index of metabolic products of the parasites,
perhaps of a toxic nature, which products, upon absorption
cause, as suggested by Neusser (15) the blood changes (eosino-
philia, hemolysis, etc.). According to Leichtenstern crystals
are constantly present in the stools of individuals suffering
from uncinaria or anguillula and are frequently found with
other forms of intestinal entozoa. The crystals may be hard
to find and may be only discovered after a laxative (preferably
calomel), which brings away the intestinal mucus in which
they lie.

A slight increase in the number of leucocytes with eosino-
philic granulations in the blood is common and a considerable
increase not rare. For example, Ashford (8) in his 19 cases
found nine showing over 8 per cent of the leucocytes present,
the highest being 40 per cent, the lowest was 2 per cent. It
appears to be established that an increased number of eosino-
philes is a common phenomenon with a variety of intestinal
parasites. According to Ehrlich and Lazarus (16), if other
conditions with an associated eosinophilia are investigated but
one explanation applicable to all can be found, namely, that
the increase in the number of these cells is the result of che-
motaxis. For example, in asthma, as pointed out by GoUasch,
there is an eosinophilia together with the appearance of
eosinophilic cells and Charcot-Leyden crystals in the sputum,
and Van Noorden finds that the number of eosinophile de-
pends directly upon the frequency and recent occurrence of
the attacks, not on some lasting constitutional peculiarity,
but upon the local action of an inflammatory irritant, since in
other individuals having eosinophilia there are no eosinophiles
in their sputum.

In a pemphigus case, Neusser showed that the biilhe con-
tained cells which were nearly all eosinophilic, but on produc-
ing artificially by a vesicant another vesicle on the same
individual, the cells were entirely neutrophilic. In Diihring's
disease (Dermatitis herpetiformis), Leredde and Perrm dem-
onstrated that at first when the vesicles are clear they contain
principally eosinophiles, whereas later, after auto-infection,
postules develop and the cells are neutrophilic.

Calamida's (9) work, already referred to, shows in a striking
manner the chemotactic influence upon the eosinophilic cells
of products obtained from an animal parasite. Capillary
tubes containing a sterile normal saline solution of an extract
made from the bodies of tape-worms were inserted beneath

370

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

the i-'kin of a dog; after a short time they became filled with
cells, the majority of which were eosinophiles.

There ai-e two possible sources for a substance positively
chemotactic for eosinophiles: (a) it may be a product of the
parasite; (b) it may be produced within the body by metamor-
phosis or degeneration of tissues.

Ehrlicli and Lazarus (16) observed that the changes in epi-
thelial and other cells seem to have some relationship to such
a positive chemotaxis. In certain skin aifections: with atro-
jjhic conditions of the gastric, intestinal and bronchial mucosa;
with some carcinomata; in lupus foci after tuberculin injec-
tion, etc., collections of eosinophilic cells occur about areas of
tissue degeneration.

The facts already cited indicate, however, that the accu-
mulation of eosinophiles with uncinaria is the result of a
specific chemotactic action of parasites attracting them to
the intestinal wall and causing an increase of their number in
tlie blood and in the spleen. That the toxic substance caus-
ing the hemolysis in uncinariasis is not identical with that
producing the eosinophilia is probable, since the anemia and
ecsinophilia bear no constant relationship to one another.
In the ease here reported the toxic substance which caused
the central necrosis in the liver was not positively chemo-
tactic for eosinophiles which were scant in number in the ne-
crotic areas, though polyniiclear leucocytes were present.

The inverse ratio that exists between eosinophiles and
neutrophiles in clinical observation has lead to the belief
that substances positively chemotactic for the one may be
negatively chemotactic for the other.

Leichtenstern had a case of severe uncinariasis with an
eosinophilia of 72 per cent. Croupous pneumonia super-
vened and this percentage dropped to 7 per cent, rising to
54 per cent after recovery from the pneumonia and falling
to 11 per cent after anthelmintic treatment; a year later it
was 8 per cent with a few worms still present. (In a case of
trichiniasis occurring in Dr. Osiers service (T. B., Gen. Med.
No. 11,387) with an eosinophilia of 37 to 44 per cent and
54 to 48 per cent polymorphoneutrophiles, showed after onset
of an acute lobar pneumonia, eosinophiles 24 per cent and
neutrophiles 67.4 per cent. The eosinophilia had disappeared
a month later (4.5 per cent).

Of the origin of the eosinophilic cells themselves there are
but three possibilities. That they spring from similar or
heterogeneous cells of the blood, or from the fixed tissue
cells elsewhere and are transported by the blood, or locally
at the site of the eosinophilic infiltration.

If they were the products of the proliferation of blood-cells,
one would expect to find in the eosinophilic cells in the
peripheral circulation signs of (1) cell division and (2) tran-
sitional forms between other cells and those with the
eosinophilic granulation. No positive evidence of cell
division in the peripheral circulation has been offered.
Transitional cells, too, are not seen, though in leukemia cells
do occur which have polychromic granulations.

Ehrlich states that in the bone-marrow all stages of transi-
tion are to be seen from specific mononuclear cells with

granules to the polymorphonuclear varieties, with either neu-
trophilic or eosinophilic granulations, as the case may be.
During this transition there is a change in the character of
the granules also, the younger cells have basophilic granula-
tions in excess which diminish proportionately to the advance
of the " ripening '" of the cell. Only the mature or ripe cells
appear in the circulating blood. The maturing or ripening
of both the cells and granules is normally equally advanced.
Under abnormal conditions, as in leukemia, the cells ripen
faster than the granules and thus ripe cells with unripe
granules may get into the circulation. These unripe granules
take a blackish stain with eosin-aurantia-negrosin, or bluish-
red or blue with eosin-methylene blue. Such cells with un-
ripe granules are in no way transitional but are immature
forms, and it is easily possible that an abnormally rapid forma-
tion of eosinophiles by the bone-marrow would permit of the
entrance of these atypical elements into the circulation.

The evidence that eosinophiles axe formed in organs other
than the bone-marrow is not conclusive. Mononuclear gran-
ular cells are not found in lymphatic tissue, and in the
spleen, as in the blood, evidence of cell proliferation and
transitional forms is not found. The removal of the spleen
far from causing any decrease in the proportion of eosino-
philic cells, causes a distinct increase.

There is even less evidence that eosinophiles are formed
locally within the foci where they are found accumulated.
Mastzellen, as Ehrlich and Biiumer (16) have shown, may be
formed locally, but there is no proof that eosinophiles can,
('. e., the existence of cell proliferation or of transitional
forms.

Brown (17) from his observation on cases of trichiniasis
came to the conclusion that the eosinophiles might be formed
locally from the neutrophiles. He observed forms typical of
neither and thought to be transitional, and concluded that
the change possibly took place in the muscles (locally) as the
proportion of eosinophiles was there greater than in the cir-
culating blood. He also thought that the change did not
take place in the circulating blood.

It is easily understood, accepting Ehrlich's theory of ripe
cells with unripe granules, that it would not be difficult to
mistake a cell with unripe granules for a transitional form.
Moreover, in the trichiniasis case reported above from the
Johns Hopkins Hospital, the cells in the blood were not at
first characteristic of typical eosinophiles, and the same ques-
tion arose as to the possibility of their being transitional
forms. Later, before the eosinophilia subsided, they became
perfectly typical. A plausible explanation seems to be that
these cells were of the nature Ehrlich described. Brown's
finding of an increased nimiber of eosinophiles near the para-
sites in the muscles could be as well, and perhaps better, ex-
plained on the theory of chemotaxis.

It seems reasonable to suppose that in cases of infection
with Uncinaria duodenalis the parasite produces in the in-
testinal canal a substance which is positively chemotactic for
eosinophilic leucocytes, thus causing a local infiltration of the
intestinal structures with eosinophiles and at times an accu-

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

371

mulation of eosinophiles in the blood. It is probable that
there is formed another toxic substance which causes hemo-
lysis and tissue degeneration.

Blanchard (18) refers to reports upon Uncinaria duode-
nalis in the United States as early as 1830 by Chabert, and
in 1815 b}' Duncan, describing an anemia among the negroes
in Louisiana; Lyell in Alabama, Heusinger and Giddings in
South Carolina were also mentioned. Little and Leather-
man made some doubtful reports of the existence of unci-
naria in Florida.

The following definite cases are on record:

Case 1. — Blickhahn (19) reported from Missouri in 1893.

The disease was contracted in Germany, the patient recov-
ered. The red blood-corpuscles were only 800,000 to the
mm., a marked leucocytosis was j^resent and the hemoglobin
was low. The presence of alpha and gamma granulations in
considerable numbers awakened a suspicion of myelogenous
leukemia.

Case 2.— Herff (20) reported from Texas in 1894.

The disease probably was contracted in Mexico. The diag-
nosis was made post-mortem. No blood count was given.
Also several indefinite cases among Italians, which were only
diagnosticated symptomatically.

Case 3. — Mohlau (21) reported from Buffalo, New
York, in 1896.

The source of disease was not stated. Recovery occurred.
The red blood-corpuscles were 4,500,000 to mm. No other
blood estimations were given.

Case 4. — Same.

The disease was contracted in New York and traced to
foreign laborers. Recovery followed. No blood counts were
given.

Case 5. — Same.

The source of disease was not stated. Recovery took place.
No blood counts were given.

Case 6. — Same.

The disease was contracted in New York and traced to
foreigners. Recovery took place. No blood counts were
given.

Case 7.— Same.

Disease contracted at St. Gotthard. Unimproved. No
blood counts were given.

Case 8.— Tcbault (22) reported from Louisiana in 1899.

The disease was contracted in New Orleans. Recovery took
place. Tlie red blood-corpuscles were 2,500,000 to mm., the
white cells were 30,000. The patient also had malaria.

Case 9. — Dyer (23) reported from Missouri in 1901.

Source of disease was not stated. Recovery took place. No
detailed blood count was given.

Case 10.— Claytor (24) reported from the District of
Columbia in 1901.

The disease developed in Virginia. Recovery took place.
The red blood cells were 1,577,000 and white cells 4400 to
mm. The hemoglobin was 30 per cent, the eosinophiles
were 5 per cent of the leucocytes present. No nucleated red

cells were seen. (Patient has since died from cerebral hem-
orrhage.)

Case 11. — Allyn and Behrend (25) reported from Penn-
sylvania in 1901.

The individual contracted the disease in Italy. Recovery
took place. Red blood cells were 1,220,000 and the white
cells 8650 to mm.; hemoglobin was 15 per cent.

Case 12. — Gray (26) reported from Virginia in 1901.

The disease was contracted in Virginia. Recovery took
place. No blood count was given. A sister of this patient
was suspected of having the disease; diagnosis was based
purely on symptoms, neither ova nor parasites were observed.

Case 13.— Sehaeffer (27) reported from Texas in 1901.

The disease was contracted in southern Mexico. Recovery
took place. The red blood cells were 2,970,000 and the white
cells were 14,300 to the mm. Hemoglobin was 57 per cent
and the eosinophiles 6 per cent of the leucocytes present.
There were also amcebte coli and ova of trichoeephalus dis])ar
in the stools.

Cases 14 and 15. — Same.

Two students; both probably recovered; both had eosino-
philia; one had malaria. No other notes were given.

Refebences.

(1) Mallory: Journ. of Med. Reseai'ch, vol. iv, p. 264.

(2) Scheube: Die Krankheiten der Warmen Lander, Jena,

1900, S. 477.

(3) Williams: Lancet, Jan. 19, 1895, p. 192.

(4) Fearnside: Brit. Med. Journ., Sept. 1, 1901, p. 541.

(5) Strong: Circulars on Tropical Diseases, No. 1. Chief

Surgeon's Office, Manila, P. I., 1901, p. 31.

(6) Rake: Journ. of Path. & Bact., Edin. and Lond., 1896,

p. 107.

(7) Roger: Brit. Sled. Journ., Sept. 1, 1901, p. 545.

(8) Ashford: N. Y. Med. Journ., April 14, 1900, p. 555.

(9) Calamida: Centralbl. fiir Bacteriolog., Sept. 21, 1901,

p. 374.

(10) Biickiers: Miinch. med. Wochenschr., 1894, S. 21 u. 47.

(11) Lntz: A'olkmann's Vortriige, Hft. 255-6, S. 53.

(12) Miiller & Reider: Arch, fiir klinisch. Med., 1891, S. 96.

(13) Zappert: Wien. klinisch. Wochenschr., 1892, S. 347.
(11) Leichtenstern : Deutsch. med. Wochenschr., 1892, S.

583.

(15) Neusser: Wiener klinisch. Wochenschr., 1892, S. 44.

(16) Ehrlich und Lazarus: Nothnagel. Specielle Path. &

Ther., 1901, Bd. viii, S. 56.

(17) Brown: Journ. of Exp. Med., vol. viii, p. 315.

(18) Blanchard: Traite de Zoologie Medical, vol. i. p. 144.

(19) Blickhahn: Med. News, Dec. 9, 1893, p. 663.

(20) Ilerff: Texas Med. Journ., June, 1894, p. 615.

(21) Mohlau: Buffalo Med. Journ., 1896-97, Ixxxvi, p. 573.

(22) Tebault: New Orieans Med. & Surg. Journ., Sept.,

1899, p. 145.

(23) Dyer: Interstate Med. Journ., St. Louis, Mch., 1901, p.

94.

(24) Claytor: Phila. Med. Journ., June 29, 1901, p. 1251.

372

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 139.

(25) Allyn & Behrend: American Medicine, June 13, 1901,

p. 63.

(26) Gray: Virginia Med. Semi-Montlily, Sept. 27, 1901, p.

269.
(37) Schaeller: Med. News, Oct. 26, 1901, p. 655.

Discussion.

Dk. Thayer. — This is, so far as I know, the first case of
this disease which has been recognized in Baltimore, de-
spite the fact that for several years we have had our eyes
well opened to the probability of its occurrence in these
regions. The fact that in the past four years we have
observed in this hospital three cases of diarrhea associated
with Strongyloides iiitestinalis, a parasite which is found
under very much the same conditions and often in associa-
tion with Uncinaria, has led us to expect that we should
soon discover cases of this nature. This parasite was first ob-
served by Dubini in 1838 in the intestinal tract of a young
woman dying in a hospital at Milan. The recognition of its
pathological importance dates from Griesinger's discovery
in 1851, that it was the cause of the so-called Egyptian
chlorosis, a very grave and often fatal form of ansemia pre-
valent in Egypt. The worm became an object of yet greater
interest to the medical world in 1880, at the time of the
excavation of the St. Gothard tunnel. Among the tunnel-
workers there develojjed an ana?mia associated often with
diarrhea and occasionally with bloody stools, which pre-
sented many of the features of progressive pernicious anaemia.
The dejecta of these patients were found to contain numer-
ous eggs of Uncinaria, together often, with embryos of the
allied Strongyloides intestitialis. The disease was studied by
Perroncito, Sahli, Bozzolo and Pagliani, Grassi and others.
While the eggs of Uncinaria and those of Strongyloides
intestinalis are extremely similar, indeed, scarcely to be dis-
tinguished, those of the fonner alone appear in the stools;
the eggs of the Strongyloides hatch within the intestinal
tract excepting in very rare instances. In several cases of
infection with Strongyloides i7destinalis studied carefully for
months, we found myriads of larva?, but only two eggs. The
larvae of Strongyloides intestinalis when first passed are from
200-400// in length and extremely active. They are in
many ways similar to those of Uncinaria, which, however,
are never found in the fresh stools. The eggs of Uncinaria
duodcnalis are elliptical structures from 55-60 fi in length
by 30 n in breadth, and when passed are in the stage of
segmentation. From twelve hours to two or three days after
passage, if kept at about 35° C, the larvae begin to escape,
and after four to eight days reach the limit of development
of which they are capable outside of the human body. It is
probable that in most instances they are introduced into
the organism through water, uncooked vegetables, or by
the hands themselves. While the disease is widely spread
in Europe, Asia, Africa, South America and in the Antilles,
but few cases have been reported in this country. The
disease is especially common among miners, brick-workers
and tunnel-workers. While infection with Uncinaria duo-

denalis results in grave and often fatal symptoms, Strongy-
loides intestinalis is a much less malignant parasite, being
associated, in the majority of instances, with chronic diar-
rheas, which, when propei'ly treated, are rarely fatal; often,
indeed, the parasite may be present for long periods of time
without producing any symptoms.

The importance of recognizing the eggs of Uncinaria
duodcnalis in the stools is great, in view of the fact that the
worms may be easily expelled. Treatment with large doses
of male fern or thymol causes the entire disappearance of
the parasites with recovery. It is an interesting fact that
while the symptoms associated with the presence of Strongy-
loides intestinalis are much milder, and amenable often, to
treatment by general measures such as are adopted in any
case of chronic diarrhea, yet it is often extremely difficult
to rid the patient of the worms; the treatment which is so
efficacious in the case of Uncinaria is often almost wholly
ineffectual in the case of Strongyloides.

The occurrence of this case should emphasize the great
importance of systematic examinations of the stools, par-
ticularlv in cases of grave anemia.

NOTES OIV NEW BOOKS.

The Principles and Practice of Medicine, desig-ned for the use
of practitioners and students of medicine. By Williaji
OsiJSR, M. D., F. R. S., F. R. C. P. (Lond.), Professor of Medi-
cine in the Jolms Hoplvins University, etc. Fourth Edition,
pp. 1-1182. {New York: D. Applctmi & Co., 1901.)

In his preface to the fourth edition of his text-book the
author says: " Bysentery, yellow fever and the plague have
attracted the attention of so many workers that it is difficult
to keep pace with the rapid progress of our knowledge." But
that he believes that this statement, to a large extent, holds
true for many other diseases, is shown by the long list of
articles, given a little later, which are wholly or partially new.
In fact it may be said that anj' one who is seeking for a strik-
ing concrete example of the advances that are being made in
medicine every year, as the result of combined clinical and
experimental stvidies, could hardly do better than note care-
fully the numerous additions and changes which have been
found necessary in order to bring up to date a work, the last
edition of which appeared barely three years ago. But in
order that a book shall serve as an every-day text-book and
not be in the main a work of reference, the author is ever
hampered by the fact that while nothing of real importance
must be omitted and while the various subjects must alwaj'S be
treated of in a readable form but at the same time compre-
hensively, any undue expansion in the eyes of the student, as
well as of the publisher, will inevitably be looked upon as the
unpardonable sin. An intuition, inborn to a certain extent
perhaps, but mainly the outgrowth of years of clinical and
pathological experience, has enabled Dr. Osier to meet these
difficulties successfully, and thanks to his broad grasp of the
various fields included in his subject he has pruned judiciou.sly,
sifted the essentials from the non-essentials and utilized to
their full extent the rich but often cumbrous and confused
masses of material with which he has had to deal. As a result
we have the same compact volume as before, but containing
within its covers an added wealth of reliable data.

Of the general characteristics of the work, sufficient has

Deckmber, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

373

been said as long ago as 1892, in the brief review which
appeared in these pages at that time. In the present edition,
the dearly bought knowledge of various diseases (tyiJhoid,
malaria, dysentery, etc.) which has accrued from the Spanish-
American, South African and Philippine camiiaigns, as well as
from some of our home epidemics (notably that of typhoid
fever in Philadelphia), has been summarized and the lessons
to be learned therefrom clearly and succinctly stated. Pneu-
monia, small-pox and cerebro-spinal fever have not been ne-
glected, and new points in treatment and diagnosis have been
added.

The ana?mias have been woi-ked over again, and in the brief
but clear description of splenomegaly, some of the author's
recent clinical experience has been introduced. Herpes zoster
has been definitely classed with the acute infectious processes.
The subject of arsenical poisoning has been enriched by the
results of studies aroused by the Manchester epidemic. The
article on aphasia has been rewritten and appears in a much
improved form. In short, the fourth edition shows everywhere
the unmistakable signs of a careful revising hand, and if Dr.
Osier has not accomplished the impossible, at any rate he has
come within a reasonable distance of so doing. The publishers
have done their work well and may be congratulated on the
general appearance of the volume.

The History of Medicine in the United States. A Collection
of Facts and Documents relating to the History of Medical
Science in this Country, from the earliest English Colon-
ization to the year 1800, with a Supplemental Chapter on
the Discovery of Anaesthesia. By Francis Kajjdolph
Packard, M. D. Illustrated. Octavo, 543 pages. {Pliiladcl-
phia and London: J. B. Lippincott Co., 1901.)

This most interesting work, which has occupied the author
for many years, is, as he says, the first attempt at a general
history of medicine in this country. He is very modest in
his claims for it, saying in his preface that " it should be
regarded rather as a series of essays and compilations, than
in the light of a continuous historical work." It could not
be supposed that an attempt to cover so large a field, when
the sources of information are limited, scattered, and in many
cases almost inaccessible, should succeed at once. It will
require much time and effort to realize one's ideal of such a
work. Nevertheless here is a good beginning of the difficult
task and we cannot be too grateful to Dr. Packard for all
his labor (doubtless to be but poorly requited, as all such
labor is), in bringing together and rendering available so
much of the early medical history of our country.

The typographical execution of the work is all that could
be asked. The illustrations number 25, the frontispiece being
a cut of the Pennsylvania Hospital, oiJcned on the 6th of
February, 1753. The other illustrations are mostly portraits
of eminent phj'sicians, 12 of whom are Philadelphians, 4
from Massachusetts, 1 each from New York, Connecticut,
New Jersej', Maryland and Georgia. The two last States
are represented by Charles Frederick Wiesenthal (repro-
duced from this Bltlletin for .July-August, 1900) and Craw-
ford W. Long. The remaining illustrations are: Edinburgh
Certificates of Dr. Asheton of Philadelphia, Surgeon's Hall,
Philadelphia, Fac-Simile of the contract between the Penn-
sylvania Hospital and the Continental Army Surgeons for
the use of the " Elaboratory " of the Hospital by the lal ter,
students' Certificate conferring the right to attend the Prac-
tice of the Pennsylvania Hospital, seal and corner-stone of the
Pennsylvania Hospital, Fac-Simile of the First Medical Pub-
lication in the colonies of North America, and the First
Pulilic Demonstration of Ether Ana'sthetization by Dr. W.
T. G. Morton at the Massachusetts General Hospital on

October 16, 1846. We would suggest to the author to add to
these in any future edition, which is certain to be called for,
portraits of the great New England surgeon, Nathan Smith,
of the patriots Joseph Warren, of Massachusetts, James
McHenry, of Maryland, Hugh Mercer, of Virginia, and John
Moultrie, of South Carolina. David Eamsay, the historian, of
Charleston, ought also to be included, and there are several
from Maryland besides McHenry who would honor the book,
as John Archer, of " Medical Hall," Harford Co., the 1st grad-
uate, a distinguished medical teacher and a statesman of note,
UiJton Scott, of Annapolis, first President of the Medical and
Chirurgieal Faculty of Maryland, Ennalls Martin, " the Aber-
uethy " of Talbot Co., surgeon in the Kevolution, Henry Ste-
venson, of iialtimore, the great inoculator, Charles Alexander
Wartield, the first to propose a separation from the mother
country and leader of the Peggy Stewart burning at Annapolis,
and John Crawford, unquestionably the ablest physician of his
day, the introducer of vaccination into Maryland, a founder of
the Society for Useful Knowledge, 1798, and of the Baltimore
General Dispensary 1S07, Grand Master of Masons, lSOl-13, who
earnestly advocated the germ theory and practiced autisept-
ically over 100 years ago. There should also be illustrations
of the earliest medical schools.

The headings of subjects are comprehensive, embracing,
besides medical events in general, medical education, epidem-
ics, medical schools, hospitals, societies, the Itevolutionary
War, bibliograiihy, legislation and the discovery of Anaesthesia.
An appendix contains: The Examination of Dr. Church, Dr.
John Morgan's Memorial, the Pennsylvania Hospital and Ke-
miniscences of the Physicians and Surgeons who have served
it, by Dr. Charles D. Meigs, List of Authorities, and Medical
Societies founded in the United States, before the year 1835.

In connection with the above, we would call the author's
attention to some Maryland events which might have been
included. Dr. Thos. Gerard, of St. Clement's Manor, arrived in
Marj'land in 1638 and took a prominent part in the events of his
day; see Thomas' recent history. Dr. Luke Barber somewhat
later was equally prominent and was mediator in the battle
between the Puritans and Royalists at Providence (Annapo-
lis), March 36, 1655. The Drs. Gustavus Brown through three
generations (1708-1804) held a distinguished place in Maryland,
all being Edinburgh scholars and two of the three being sum-
moned to Washington in his last illness. The medical school
projected in Baltimore in 1789, while it failed, deserves some
mention, resulting in courses on obstetrics and anatorny, by
Drs. George Buchanan and the younger Wiesenthal. There
were many Maryland physicians eminent in the Continental
Army, and if the surgeons of Connecticut or the other colonies
are mentioned, we see no reason why the Marylanders should
not be included also. Of medical societies some mention should
be made of the Baltimore Society of 1788-'90, of the Harford
Medical Society, founded by John Archer and his pupils at
" Medical Hall," April 1st, 1797, and of the Maryland Society for
Useful Knowledge, founded December 13, 1798, by Jos. Priestley,
John Crawford and others, before which a large number of
medical papers were read between 1798 and 1806. The Mary-
land Hospital was founded at Baltimore, February 30, 1798,
as a general hospital, including the insane, and fulfilled here
the same role as the Pennsylvania Hospital until 1828, when it
became the Maryland Hospital for Insane, under which title it
still exists.

In connection with the founding of the Medical and Chirurgi-
eal Faculty of Maryland, it was hardly fair to give it ju.st
/sre lines in a section embracing 55 pages. And, in connec-
tion with the subject of vaccination, we cannot see how Dr.
James Smith, of Baltimore, can be omitted, who, while not'
actually the first to practice it (he first used it at the alms-
house. May 1, 1801), probably did more than any one to spread

374

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 139.

it over the country and make it known to the profession
ami people, establishing as early as March ^5, 1803, a vaccine
institute, which later became a State and then a national
institute. One of the objects of this institute was to provide
vaccine virus gratuitously for the poor. " The services of
this physician in promoting the introduction and spread of
this great boon and in arresting reiJeatedly epidemics of
small-pox, entitle him to the eternal gratitude of this com-
munity." Nor is Dr. Smith alone to be mentioned; the pro-
fession throughout the State was full of zeal in behalf of
the great discovery, in their eageimess to secure its adoption
offering pecuniary rewards to those who would submit to
its performance. It may also be mentioned that the Medical
and Chirurgical Faculty early gave the new discovery its formal
approval and was perhaps the first medical organization in the
country to do so.

As we have already indicated, the work is rather open to
criticism on the ground of omission than of commission. To
the writer, the thrilling accounts of the several epidemics
of yellow fever in Philadelphia, and the sketch of the medical
deiJartment of the Continental Army were the most inter-
esting parts of the book. The latter especially threw a new
light upon our Kevolutiouary struggle and made clearer the
difficulties under which our forefathers labored and their
merits in persevering through the long and terrible sufferings
which they endured. "Just think of Dr. Morgan's being un-
able to dole out more than two scalpels to the surgeon who
was to have charge of the wounded in what it was antici-
pated would be a bloody battle, and of the suggestion that a
razor should be used instead of a scalpel."

At page 62, under the heading, " The Earliest liecorded
Autopsies in America," it is said that the earliest mention of
an autopsy here is to be found in " An Account of Two Voy-
ages to New England," published at London, in 1674, by John
Josselyn, an Englishman, who had spent some time in New
England. It was that of " a young maid who was troubled
with a sore pricking at the heart, still as she leaned her
body or stept down with her foot to the one side or the other."
She died, and her friends, desirous of discovering the cause
of the trouble, had the body opened, whereupon " they found
two crooked bones growing upon the top of the heart which,
as she bowed her body to the right or the left side, would jab
their points into one and the same place, till they had woru a
hole quite through." Doubtless there were many cases in the
older colonies before this, which a search of the records might
reveal. The late Dr. John E. Quinan, who was the most inde-
fatigable antiquarian we have ever had in these parts, un-
earthed several from the Maryland records. In 1642 he found
a report of an " Enquest taken at St. Maries upon the view
of the body of Ann Thompson." In 1643, he found an " En-
quest on an Indian ladd killed by John Dandy," the report
being signed by " George Binx, Foreman," who elsewhere is
styled " Licentiate in Physicke." On September 24, 1657, an
inquest was held on Henry Gouge, at Patuxent, " by Rd. Mad-
docks and Emperor Smith, Chirurgeons, by order of the Coun-
cil," the chirurgeons being allowed one hogshead of tobacco
each as fee. On August 8, 1670, an autopsy was done " by
John Stanley and John Peirce, Chirurgeons," on the head of
Benjamin Price, who had been killed by Indians. (M. S.
Council Book.) In 1671 an act was passed allowing 250 pounds
of tobacco to the coroner for an inquest. An examination of
the records at the Historical Society might multii)ly these
instances.

Of "Juries of Women" (p. 59, not given in the index), there
are several recorded in Maryland earlier than those given by
the author. In 1652, a jury of matrons decided as to the
alleged pregnancy of a murderess. In 1656, a similar jurj-

decided as to a case of supposed pregnancy, and another as
to an alleged infanticide, in 1658, a jury of women was
ordered by the Court of Kent County to report upon a case
of alleged infanticide, and rendered through their forewoman,
Mary Vickers. a verdict " that the accused, Hannah Jackson,
is clear from the bearing and never had a child." In 1659, a
similar jury decided as to the pregnancy of a woman convicted
of felony, etc., etc.

The brief allusion to the two voyages of Capt. John Smith
from Jamestown, in 1608, recalls the interesting descriptions
written of them by the physicians accompaujing — " Walter
Ivussell, Gentleman, doctor of physicke," and " Anthony Bag-
nell, Chirurgeon." Smith on these occasions thoroughly ex-
plored the Chesapeake Bay, and even entered the Patapsco
Eiver, probably beholding the site of the City of Baltimore.
From the resemblance of the clay on the river banks to " bole
armoniack (terra sigillataj," they called it the "Bolus." By
the way, this article is mentioned at p. 30 of Packard's book in
" Keceipts to Cure Various Disorders," 1643. Smith was in
search of a northwest passage, and the physicians, being the
educated men of the parties, were appointed to draw up the
accounts of the expedition, which they signed with their names,
as may be seen in Smith's General History, Chap. V.

At p. 160, it is stated that the first to receive a medical
diploma in North America was Daniel Turner, who was thus
honored by Yale College in 1720, on account of his benefac-
tions to the college. As the medical department of Yale was
not founded until 1813, it would be interesting to kuow whether
it possessed the Icyal right at this time to confer such a degree.
Of course, if it had not, such action was invalid. We do not
know of another such case. Would Princeton, Washington
and Lee, Haverford, etc., be able to confer a medical degree
now?

At p. 161, Dr. John Archer's diploma is reproduced, "proba-
bly the first medical diploma awarded after a course of studj'
in America." It was issued in 1768 by the " Collegium et
Academia Philadelphiensis," and, as is well known, forms
one of the treasures of the Medical and Chirurgical Faculty
of Maryland. It is unfortunate that more care was not taken
in reproducing this important document, which ought to have
been given in fac-simile. A facsimile of it was readily available
in the Centennial number of the Maryland Medical Journal,
April 29, 1S99. Numerous mistakes occur in the author's copy,
some of which are " pervenorint," " ingenum," omission of the
words after " Archer " — " apud nos Praelectionibus in medi-
cina omnium Professorum " — , " Vigillissimo," " Liberis," " ma-
jori," " Johannem," " Acadae," " Angi," " clinicus," " Praxeos,"
" in " omitted before " nosocomio," etc. These errors are
easily seen by referring to the facsimile.

At p. 36, it is said that Dr. John Glover, of Massachusetts,
received the degree of M. D. at the University of Aberdeen
about 1650. We doubt very much if that degree was given at
Aberdeen until long- after that date. The medical school was
not established until about the middle of the ISth century,
and we have before us the diploma of Dr. Jauies Walker, of
Maryland, dated at Aberdeen, December 31, 1724, and signed
by Drs. Gregory, Donaldson, Skeene and Burnett, but not con-
ferring any degree.

The following " first " things will probably be of interest
to the reader: 1st medical society founded in Boston in 1735,
lasted six years; 1st State Society founded in New Jersey in
1766, and still in existence, although with a break from 1795 to
1807 — six State societies were founded before 1800; 1st dis-
pensary founded in Philadelphia in 1786; inoculation for small-
pox introduced into England by Lady Mary Wortley Montague,
April, 1721, and on June 27, 1721, Dr. Zabdiel Boylston inocu-
lated successfully his only son and two negro servants; vac-

Dkcembek, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

375

cination was introducecl into America in the summer of 1800
simultaneously by Dr. Benjamin Waterhouse, of Boston, and
Dr. John Crawford, of Baltimore; the 1st vaccine institution
— " Institution for the Inoculation of the Kine Pock " — was
organized in New York City on January 11, 1803 [Dr. James
Smith's coming two months later]; 1st feetable that of the
New Jersey Society, 1766; 1st medical college instituted in
Philadelphia in 1765; 1st course of lectures on the practice of
medicine, delivered by Dr. John Morgan, 1766; 1st medical
publication — Thacher's " Brief Rule on Small Pocks " — 1677;
1st ofhcial pharmacopreia issued under the auspices of the
Massachusetts Medical Society, 1808 (a private pharmacopoeia
had been published at Lititz, Pa., by Dr. William Brown, of
Charles Co., Md., in 1778); 1st course of clinical lectures, de-
livered by Dr. Bond (a Marylander), at the Penna. Hospital,
1766; 1st use of anaesthetics in surgical operations by Dr.
Crawford W. Long, of Georgia, March 30, 1842.

At p. 11 it is said Mr. Pratt was appointed surgeon to the
plantation (Mass.), March 5, 1682, and on p. 12 we are told
that the same gentleman was shipwrecked and drowned in
1645! At p. 90 it is said vaccination ^vas announced by Jenner
in 1779! "Occasional" is used for "occasion" at p. 194. We
feel sure that the critical Dr. Holmes never penned " Alblnius "
and " Gaubrus," p. 231. Inoculation was not introduced in
1712, p. 432. As we have already intimated, some additions
fl'ill have to be made to the seventeen medical societies
founded before 1800, p. 525. In the list of authorities " chiefly
consulted." p. 521-5, we note biit one from Maryland — Mc-
Sherry's History of Maryland; and in the entire index of six-
teen pages there are but thirteen allusions to Maryland doc-
tors!

A " medical history of the United States " cannot be limited
to a few centres, however important the part they have taken
in medical progress may appear. The historian must write
for all and wnthout bias. One circumstance alone, that among
the names of sixty-three .Americans in the list of graduates
in medicine in the University of Edinburgh between 1758 and
17S8, Stille found "that but one of these students came from
the New England Colonies" (p. 156), indicates that there must
have been man.y eminent men in the Middle and Southern
Colonies who left their impress upon their age, by reason of
the standing and acquirements which such a training secures.
That Maryland has deserved more attention than the author
has given it we have furnished good evidence, and we feel sure
he will be richly rewarded for his trouble if he will consult
the historical records of this State, and especially Quinan's
Annals of Baltimore, the Maryland Medical Journal. The
Johns Hopkins Bftxetin, and the forthcoming "Medical .An-
nals of Maryland "—the Centennial Memorial of the Medical
and Chirurgical Faculty of Maryland. E. F. C.

A Text-Book of the Practice of Medicine by Dr. Herman
EiCHHORST, Professor of Special Pathology etc., Zurich.
Authorized translation from the German. Edited by
Augustus A. Esiiner M. D., Professor of Clinical Medicine,
Philadelphia Polyclinic. With 84 illustrations; 2 volimies.
{PhUadclphiii: W. B. HdniKlcrs A Co.. 1901.)
The above translation as appears from the advertisement is
a condensed edition of the author's larger work on Special
Pathology and Therapeutics. The book presents in general
the usual characters of a text-book on the Practice of Medi-
cine, but the author has added chapters on diseases of the
bladder, the male sexual organs and skin diseases. Reference
is much facilitated by the employment of five different types.
Although the book contains about twelve hundred pages the
individual chapters are brief. The diseases accompanied by
an elevation of temperature are illustrated by fever charts

which are written sometimes in centigrade scale, sometimes
in Fahrenheit. When temperatures are mentioned in the text
they give the usual American scale of Fahrenheit as well as
the German scale of centigrade.

An especially valuable feature of the book is that it gives
the methods of making clinical and microscopic tests, in
their appropriate places, such as the method of staining for
the gonococcus, chemical examination of the stomach con-
tents, the tests for sugar in the urine, etc.

Special attention is given to treatment. Medicinal treat-
ment is written in English in the form of prescriptions, and
the doses of drugs employed are given, both in the metric
and apothecary systems.

The paragraphs on the European watering places and baths
will be of especial interest and value to Americans.

In a few places the statements will be found rather unclear.
For example (vol. i, p. 207). "The gastric contents are ob-
tained by expression with the aid of a soft stomach-tube four
hours after, and a test meal one hour after, a test breakfast."

And (vol. ii, p. 36). "The internal capsule is the white med-
ullary mass lying to the median aspect of the optic thalamus
and the caudate nucleus, and to the lateral aspect of the
lenticular nucleus," which must have been reversed in tran-
scription.

Altogether the book is an excellent one of its kind. Its com-
7)letene.ss, yet brevity, the clinical methods, the excellent
paragraphs on treatment and watering places, will make it
very desirable for students, and for practitioners, who have
little time to read. E. B. B.

The Treatment of Fractures. By Ciias. L. Scudder, M. D.,
Assistant in Clinical and Operative Surgery, Harvard
Medical School. Second edition, revised and enlarged.
Octavo, 433 pages, with nearly 600 original illustrations.
(PJiiladelpTiM and London: W. B. Sannders & Co., 1901.)
Polished buckram, $4.50 net.

A review of the first edition of this excellent work was
published in the January Bulletin. There is little to be added
in reference to the present edition except to say that the book
has been thoroughly revised. Many X-ray plates have been
reproduced to assist in familiarizing the reader with the study
of such plates. Numerous other new illustrations have been
added, and the book has been considerably enlarged.

Libertinism and Marriage. By Dr. Louis Jullibn (Paris). Sur-
geon of Saint-Lazare Prison; Laureate of the Institute, of
the Academy of Medicine, and of the Faculty of Medicine
of Paris. Translated by R. B. Douolas. Pages v-169.
(Philadelphia: F. A. Davis Company, Puhllshers, 191!i-16 Chcn-y
Street.)

The object of this little book is good; its subject-matter is
of vital importance to the health of women, especially married
women and mothers; its author has had exceptional oppor-
tiinities for the observation and studj- of the effects of vene-
real disease and the words of warning which he \itters against
the evils of uueured venereal disease are forcible and earnest.
The style of the book, however, is not in keeping with the
gravity of the purpose of the writer, and the treatment of the
subject is popular rather than scientific. It would have been
productive of greater good in America if the topics had been
discussed in a higher tone. The translation is not always
happy. The book is well printed and attractively bound.

The Proceedings of the New York Pathological Society for the
years 1899 and 1900.

Beside the mass of short reports of cases and abstracts of
pathological investigations, the volume contains the Middleton-

376

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

Goldsmith Lecture by Dr. Flexner on the Etiology of Tropical
Dysentery. In this lecture he arrives at the conclusion that
the bacillus of Shig-a (with which the organism isolated by
himself is identical) is of paramount etiological importance,
at least, in a great group of cases. Among the various reports,
those of Lartigau on Typhoid Uterine Infection, in which he
reviews the literature, and on hyperplastic intestinal tuber-
culosis, are of especial interest. Very ingenious, too, is
Hodenpyl's investigation of pneumonoconiosis from the chem-
ical standpoint. While the reports are very brief, there is a
great deal of instructive and suggestive material contained in
the book.

Infant-Feeding in its Relation to Health and Disease. By
Louis Fischer, M. D. Containing 52 illustrations, with 23
charts and tables, mostly original. (Philadelphia, Chicago:
F. A. Davis Comiiaiti/, PiihU^ihcrs, 1901.)

There are many i)oints of interest in this little volume, al-
though the book is so poorly arranged that it is somewhat con-
fusing. It is divided into two parts. The iirst considers the
anatomy and phy-siology of the infantile digestive tracts, the
section on digestive ferments being especially thorough for a
text-book of this size. Then follows the chemistry of milk,
breast-feeding and kindred subjects, and the modification of
cow's milk.

We note with pleasure a number of tests for the adulteration
of milk. There are also some very good diets for the nursing
mother, although we are somewhat at a loss to understand
why zwieback is mentioned in a book apparently intended for
American practitioners.

The second part of the work treats largely of feeding by
infant foods, and of the diseases arising from deficient nutri-
tion. The chapter on infant-stools is especially to be com-
mended. It is to be regretted that the subject of summer
diarrhoeas is not considered, and that so little space is allotted
to the subject of premature infants and incubation. Few sub-
jects are of more interest.

The author appears very enthusiastic over the Gaertuer
milk, and strongly condemns the use of laboratory milk. In
its place, for cases demanding artificial feeding, he would
substitute raw cow's milk, diluted as occasion requires. He
states that if pure cow's milk can be obtained, pasteurization
and sterilization are more harmful than otherwise. While this
is doubtless true, yet, bearing in mind the uncertainty of ob-
taining pure milk except at the " laboratories," and the hosts
of infants affected with summer diarrhoeas, it is our opinion
that there are few truer friends to the infant than the methods
of pasteurization and sterilization now in vogue.

The volume contains many references, mostly to European
sources, yet it appears to us somewhat incomplete. We believe
that reference to men who feed undiluted cow's milk to chil-
dren at birth, and to sick infants in the early months of life,
had better be omitted (see page 101), and in its stead would
substitute mention of those who, like Rotch, Wescott and
others, by their careful and painstaking work, have done much
to put the stud}' of infant feeding upon scientific lines.

The author has undoubtedly had a wide experience, and we
hope to see a second edition of his work, better arranged and
free from the errors in proofreading that mar the text.

F. W. L.

A Text-Book on Practical Obstetrics. By Egbert H. Grandin,
M. D., with the collaboration of George W. Jarman, M. T>.
Third Edition, Revi.sed and Enlarged. Illustrated with 52
full-page photographic plates and 105 illustrations in the
text. Pages xiv-511. {Philad-clphia: F. A. Davis Company,
Ptimishers. iai},-16 Cherry Street.)
New text-books on obstetrics should present unusually

strong reasons for crowding a field already well filled. The
present edition of Drs. Grandin and Jarman's work, although
somewhat enlarged and considerably improved, contains noth-
ing which is not found in many other works of similar size,
and offers an unusually large number of points for criticism.

A chapter dealing with anatomy and embryology has been
added to the volume, but the authors have not taken advantage
of recent embryological investigation, and have presented the
views of former years, derived from the study of the lower
mammals, and disproven in large part b\' the work of Peters,
Spee, Selenka and others.

The recommendation of manoeuvres that require a finger in
the rectum for delivery in a normal case, is so contrar}' to all
modern ideas of proper technique, that mere mention of it
should be sufficient to condemn it. It is also rather remark-
able that no mention is made of deciduoma malignum. Lack
of space prevents the mention of other omissions.

The illustrations are but fair. They are mostly photographic
reproductions, and although well done in some instances, they
are badly chosen and do but little to properly illustrate the
text.

The volume must necessarily suffer unfavorable comparison
with other obstetrical text-books of similar size and cost.

F. W. L.

Obstetric and Gynecologic Nursing. By E. P. Davis, A. M.,
M. D., Professor of Obstetrics in Jefferson Medical College
and Philadelphia Polyclinic. 12mo, volume of 402 pages,
full}' illustrated. (Philatlelphiu and London: W. B. Saun-
ders cf- Co., 1901.)

This is an exceedingly attractive little volume. Dr. Davis
has i)resented the subject in a very pleasant manner, and with-
out going into details as to the mechanism of labor, or the
mechanical steps of surgical procedures, he has embodied the
objective points in an instructive way. The observance of
aseptic technique is everywhere emphasized, and the duties
of the nurse in various emergencies are presented in careful
detail. The appendix contains a short dietary, and methods
for the preparation of surgical supplies.

The book should be of value not only to the nurse but to
the physician. F. W. L.

The Acute Infectious Diseases of Childhood. By Marcus P.
Hatfield, A.M., M. D., Chicago. (Chicayo: G. P. Engel-
hard d Company, 1901.)

This is a serviceable little volume of 135 pages in which the
author treats of the following diseases of childhood: Scarla-
tina, measles, German measles, parotitis epidemica, pertussis,
varicella, variola, and la grippe. It is a good epitome of our
knowledge of these diseases brought up to date, and will be
useful both to the student and practitioner.

Sajous's Annual and Analytical CycloiJicdia of Practical Medi-
cine. Volume VI, Diseases of Rectum and Anus to Zinc.
(Philadelphia, New York, Chicago: F. A. Davis Company Puh-
lishers, 1901.)

This volume completes the first series of this work. The
first one ai^peared in 1898, so that the subject-matter covered
in the sis volumes has been completed in about three years.
The value of the entire work is much enhanced by the comple-
tion of this last volume, for we can now get information on
practically all diseases and therapeutic remedies in the cate-
gory from A to Z. This was not the case previous to the
completion of the entire series, an objection which is always
a serious one in any system in which the diseases are treated
alphabetically.

Decembek, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

377

The present volume contains articles on some important
diseases which have been written by well-known authorities.
Thus, the article on " Eheumatism," was written by Levison,
of Copenhag-en; "Diseases of the Stomach," by Stewart, of
Philadelphia; " Surgery of the Stomach and Intestines," by
Keen and Tinker, of Philadelphia; and "Yellow Fever," by
Surgeon-General Wyman, of Washington.

The success of the Annual and Analytical Cyclopsedia is in
large part due to the editor and his admirable corps of asso-
ciates. The general practitioner in particular will find the
work a most useful reference hand-book.

Diseases of the Intestines. By Dr. I. Boas, Berlin. Authorized
translation from the first German Edition with Special Addi-
tions. By Seymour Basch, M. D., New York City. (New
York: D. AppJeton rf Company, 1901.)

This translation of Boas's admirable treatise on Diseases of
the Intestines will be welcomed by physicians in this country.
The author's reputation as an authority on stomach diseases
is a sufficient guarantee that the subject has been carefully
treated. It is the final volume of the author's work on dis-
eases of the gastro-intestinal tract.

The volume contains 562 pages with 47 illustrations in the
text. The first two introductory chapters deal with the an-
atom}', histology and physiology of the intestines. The sub-
ject-matter proper is divided into two parts. Part I deals
with the methods of examination of the patient and of the
intestinal contents. There is also a general consideration of
the dietetic, hydrotherapeutic. electrical and medicinal treat-
ment of intestinal diseases. Part II is devoted to the consid-
eration of special intestinal diseases. We regret to observe
that the author relies too much on the conservative treat-
ment of appendicitis. This is unfortunate, as experience has
shown that too many deaths from appendicitis are due to the
general practitioner not recognizing the gravity of the dis-
ease and of the symptoms in individual cases. An author, in
our opinion, cannot impress too strongly on physicians the
great importance of having a surgeon see all cases of appen-
dicitis early in the attack, so that much valuable time may
be eventually gained should an operation be necessary. The
translator, however, has done much to counteract the views of
the author by insisting on the importance of early surgical
interference in proper cases.

Diagnostics of Internal Medicine. By Glentworth Reeve
Butler. A. M.. M. D., Brooklyn. (New York: D. Appleton £
Co., 1901.)

When a new text-book on the Practice of Medicine or on
Physical Diagnosis appears, one is led to make the mental
comment, " Is it possible that there is place for still another? "
We feel, however, that the author and publishers have been
fully justified in placing this excellent work before the medi-
cal profession and particularly the students of medicine.

The volume comprises 1059 pages with fi^ve colored plates and
246 illustrations and charts in the text. The illustrations are
unusually well executed and add much to the value of the work.
The subject-matter is divided into two parts. The first part
deals with the symptoms of disease and their indications, and
occupies a total of 654 pages. This section, although not
treating the subject of Physical Diagnosis in the usual way,
includes everything that is usually taken up under this heading.
An important feature of this part is the clear way in which the
author has succeeded in explaining for the student and prac-
titioner various phenomena of disease which often remain
mj'steries for years after one has commenced the study of
medicine. The second part is devoted to the study of the vari-
ous diseases and their characteristics as it is usually taken
up in works on Practice of Medicine. The knowledge that
has been acquired in the first part is brought into practical
application in this section.

The volume is thoroughly up to date and little of value in
the differential diagnosis of disease has escaped the author.
We believe that the work will be found of great service to the
students and practitioners.

Clinical and Pathological Papers from the Lakeside Hospital,
Cleveland. Series 1, 1901.

This is the first volume of reports to appear from the Lake-
side Hospital. It contains the more important papers that
have been published from the hospital during the past year.
There are eleven clinical and eight pathological and experi-
mental papers. The volume is really a collection of reprints
and consequently there is no uniformity in the quality of the
paper nor in the letter-type used. Many of the papers are
of great interest, but may not be reviewed as they have already
been published in various American medical journals.

INDEX TO VOLUME XTT OF THE JOHNS HOPKINS HOSPITAL BULLETIN.

Abdominal tumor containing a dermoid cyst, 25.

Abel. J. J. Further observations on epinephrin, 80; — On the

behavior of epinephrin to Fehling's solution and other char-
acteristics of this substance, 337.
.Abstract of interim report on yellow fever by the Yellow Fever

Commission of the Liverpool School of Tropical Medicine, 4S.
Adeno-carcinoma, primary, of the Fallopian tube, case of, 315.
.'Advances made in medical and surgical diagnosis by the

Rontgen method, 363.
Amberg, S. A contribution to the study of amoebic dysentery

in children, 355.
Anatomy, study of, 87.
Anchyloses, hereditary, or absence of various phalangeal joints

with defects of the little and ring fingers, remarkable cases

of, 129.
Architecture of the gall bladder, 126.
Arterial disease, possibly periarteritis nodosa, case of, 195.

Asthma with cyanosis, extensive purpura, painful muscles, and
eosinophilia, case of, 17.

Axillary artery in man, composite study of, 136.

B. mortiferus, report upon, 216.

Bacilli, aerobic spore-bearing, notes on, 13.

Bacillus mucosus capsulatus group, report of a case of fulmi-
nating hemorrhagic infection due to an organism of, 45.

Bacteriology of cystitis, pyelitis and pyelonephritis in women,
4.

Balantidium coli (Stein), preliminary note of a case of infec-
tion with, 31.

Bardeen, C. R. A new carbon-dioxide freezing microtome, 112;
— Born's method of reconstruction by means of wax plates
as used in the anatomical laboratory of the Johns Hopkins
University, 148; — Use of the material of the dissecting room
for scientific purposes, 155.

Barker, L. F. On the study of anatomy, 87.

378

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

Basement membranes of the tubules of the liidney, note on, 133.

Benee Jones' albumosuria assoeiatetl with multiple myelonui,
two examples of, 38.

Bettmann, M. Fibrinous bronchitis, 299.

Bilateral relations of the cerebral cortex, 108.

Blooflgood, J. C. Two cases of acute pancreatitis, 26.

Blood-vessels of the human lymphatic gland, 177.

Blood-vessels, intrinsic, of the kidney, and their significance
in nephrotomy, 10.

Blumer, George, and Laird, A. T. Report of a case of fulminat-
ing hemorrhagic infection due to an organism of the bacillus
mucosus capsulatus group, 45.

Books received, 30, 191, 230, 353.

Born's method of reconstruction by means of wax plates as
used in the anatomical laboratory of the Johns Hopkins
University, 148.

Brown, T. R. Abstract. The bacteriology of cystitis, pyelitis
and pyelonephritis in women, 4.

Brodel, Max. The intrinsic blood-vessels of the kidney and
their significance in nephrotomy, 10.

Brush, C. E., Jr. Notes on cervical ribs, 114.

Buckler, H. W. Pulmonary tuberculosis in Baltimore, 288.

Calvert, W. J. On the blood-vessels of the human lymphatic
gland, 177.

Carcinoma diagnosed by means of paracentesis abdominis, re-
port of a case; with some remarks on the diagnostic value
of examinations of serous effusions, 310.

Carcinoma of the Fallopian tube in hyperplastic salpingilis,
genesis of, etc., 55.

Carcinoma of the male breast, 305.

Case of arterial disease, possibly periarteritis nodosa, 195.

Case of a.sthma with cyanosis, extensive purpura, painful mus-
cles and eosinophilia, 17.

Case of primary adeno-carcinoma of the Fallopian tube, 315.

Cerebral cortex, bilateral relations of, 108.

Cervical ribs, notes on, 114.

Charcot's joints involving both knees, case of. 296.

Cholelithiasis, relation of to disease of the pancreas and to
fat-necrosis, 19.

Chorea with embolism of central artery of the retina. A short
review of the embolic theory of chorea, 321.

Cirrhosis of the stomach, 25.

Cold storage, preservation of anatomical material in America
by means of, 117.

Cole, E. I. Frequency of typhoid bacilli in the blood, 203.

Comiiarative study of the development of the generative tract
in termites, 135.

Composite study of the axillary artery in man, 136.

Concerning a definite regulatory mechanism of the vaso-
motor centre which controls blood-pressure during cerebral
compression, 290.

Cone, S. M. Tendon transplantation, 259.

Congenital absence of the abdominal muscles, with distended
and hypertrophied urinary bladder, 331.

Contribution to the study of amoebic dysentery in children, 355.

Cordell, E. F. The medicine and doctors of Horace, 233.

Gushing, H. Concerning a definite regulatory mechanism of
the vaso-motor centre which controls blood-pressure during
cerebral compression, 290.

Cystitis, pyelitis and pyelonephritis in women, bacteriology of,
4.

Dabney, W. M., and Harris, N. MacL. Report upon a case of
gonorrheal endocarditis in a patient dying in the puerperium,
with reference to two recent suspected cases, 68.

Dacryoadenitis, tubercular, and conjunctivitis, containing the
report of a probable case ending in spontaneous recovery
and a review of the previous literature on tubercular dacryo-
adenitis, 349.

Dare, Arthur. Demonstration of a new hemoglobinometcr, 24.

Development of the human diaphragm, 15S.

Development of the nuclei pontis during the second and tliird

months of embryonic life, 123.
Development of the pig's intestine, 102.

Diabetes mellitus associated with hyaline degeneration of the
islands of Langerhans of the pancreas, 263.

Diaphragm, human, development of, 158.

Diptera as carriers of diseases — Pare-Declat, historical note
u])on, 240.

Diphtheria bacillus, ulcer of the stomach caused by, 200.

Discussion: Dr. Fulton, Observations upon smallpox, 298; —
Dr. Futcher, Abdominal tumor containing a dermoid cyst,
26; — Case of asthma with cyanosis, extensive purpura,
painful muscles and eosinophilia, 17; — Diabetes mellitus
associated with hyaline degeneration of the islands
of Langerhans of the pancreas, 264; Exhibition of
surgical cases, 218; — Dr. Hunner, The intrinsic blood-ves-
sels of the kidney and their significance in nephrotomy, 216;
— Dr. Opie, Two cases of acute pancreatitis, 26; — Dr. Osier,
A case of arsenical neuritis, 221; Exhibition of surgical cases,
17; Secondary sj'philitic eruption, 22; — Dr. Porter, Observa-
tions upon smallpox, 299; — Dr. Smith, Observations upon
smallpox, 299; — Dr. Stiles, Protozoic and blastomycetic der-
matitis, with lantern-slide demonstrations and exhibition of
a case, 296; — Dr. Thayer, Exhibition of medical cases, 262;
Exhibition of surgical cases, 17; The relation of cholelithiasis
to disease of the pancreas and to fat-necrosis, 20;- — Dr. Welch,
Case of asthma with cyanosis, extensive purpura, painful
muscles, and eosinophilia, 17; A case of rheumatism with
fibroid nodules, 216; Exhibition of medical cases: Chronic
jaundice with xanthoma multiplex, 220; Exhibition of patho-
logical specimens: Vegetative endocarditis, cystic kidney,
carcinoma of gall-bladder, 22; Exhibition of surgical cases,
18; The intrinsic blood-vessels of the kidney and their sig-
nificance in nephrotomy, 216; Observations on blood in
typhoid fever, 22; The para.site of cancer, 295; The relation
of cholelithiasis to disease of the pancreas and to fat-
necrosis, 20; Report upon B. mortiferus, 218.

Drainage of the bladder and cystoscopic examinations, 29S.

Drepanidium, life history of, 300.

Durham, H. E., and Myers, W. Abstract of interim report on
yellow fever by the Yellow Fever Commission of the Liver-
pool School of Tropical Medicine, 48; — The life history of
drepanidium, 300.

Dysentery, amoebic, in children, contribution to the study of,
355.

Elting', A. W. Osteitis deformans with report of a case, 343.

Endocarditis, gonorrheal, in a patient dying in the puerperium,
report upon a case of; with reference to two recent sus-
pected cases, 68.

Enteritis with anajmia, caused by Uncinaria duodenalis, patho-
logical report upon a fatal case of, 366.

Epinephrin to Fehling's solution, and other characteristics of
this substance, on the behavior of, 337.

Epistaxis, recurring, associated with multiple telangiectases of
the skin and mucous membranes, on a family form of, 333.

Eruption, secondary syphilitic, 21.

Etiology of acute hemorrhagic pancreatitis, 182.

Exhibition of pathological specimens: Vegetative endocarditis,
cystic kidney, carcinoma of gall-bladder, 22.

Experimental study concerning the relation which the prostate
gland bears to the fecundative power of the spermatic fluid,
77.

Filjrinous bronchitis, 299.

Fiftieth anniversary of the invention of the oi^hthalmoscope,
243.

Decembee, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

379

Finnej-, .1. M. T., and Pancoast, O. B. A portable operating-
outfit, 206.

First nephrectomy and first cholecystotomy, witli a sketch of
the lives of Doctors Erastus B. Wolcott and John S. Bobbs,
247.

Ford, W. W. Notes on aerobic spore-bearing- bacilli, 13.

Fowler, H. .\. Model of the nucleus dentatus of the cerebel-
lum and its accessory nuclei, 151.

Friedcnwakl, H. The fiftieth anniversary of the invention of
the ophthalmoscope, 243.

Frequency of gall-stones in the United States, 2.53.

Further observations on epinephrin, SO.

Futcher, T. B. Exhibition of medical cases: A case of Char-
cot's joints involving- both knees, 296; Secondary syphilitic
eruption, 21.

Gall-bladder, architecture of, 126.

Gall-stones in the United States, frequency of, 253.

Generative tract in termites, comparative study of the develop-
ment of, 135.

Genesis of carcinoma of the Fallopian tube in hyperplastic
salpingitis, with report of a case and a table of twenty-one
reported cases, 55.

Gynecological cases, report of, 23.

Halsted, W. S. Eetrojection of bile into the pancreas, a cause
of acute hemorrhagic pancreatitis. 179.

Hamburger, L. P. Two examples of Bence Jones' albumosuria
associated with multiple myeloma, 38.

Harris, X. MacL. Report upon B. mortiferus, 216.

Harri.=;, N. MacL., and Dabney, W. M. Report upon a case of
g-onorrheal endocarditis in a patient dying in the puerperium;
■with reference to two recent suspected cases, 6S.

Harrison, R. G. On the occurrence of tails in man, with a
description of the case reported by Dr. Watson, 96.

Healed amoebic abscess of the liver, and amoebic abscess of the
lung: Exhibitions of specimens, 219.

Hemog'lobinometer, exhibition of a new, 24.

Hemorrhag-e in chronic jaundice, 264.

Historical note upon diptera as carriers of diseases — Pare-
Declat, 240.

History and work of the Saranac Laboratory for the study of
tubercidosis, 271.

Hitzrot, J. AL A composite study of the axillary artery in
man, 136.

Hurdon, E. A case of primary adeno-carcinoma of the Fal-
lopian tube, 315.

Hypere.xtension .as an essential in the correction of the deform-
ity of Pott's disease, with the presentation of original
methods, 32.

Intrinsic blood-vessels of the kidney and their significance in
nephrotomy, 10.

Introductory note to Drs. Durham and Myers's report, 48.

.laundice, chronic, with xanthoma multiplex, 220.

,lohn W. Garrett International Fellowship), 188.

Kellj', H. A. Drainage of the bladder and cystoscopic examina-
tions, 298; — A historical note upon diptera as carriers of
diseases — Pare-Declat, 240; — The removal of pelvic inflam-
matory masses by the abdomen after bisection of the uterus,
1.

Kerr, A. T. On the preservation of anatomical material in
.\nierica by means of cold storage, 117.

Knopf, S. A. Respiratory exercises in the xirevenlion and
treatment of pulmonary tuberculosis, 282; — The prevention
of tuberculous diseases in infancy and childhood, 271.

Knower, H. McE. A comparative study of the development of
the generative tract in termites, 135.

Knox, J. H. M. Lipo-myoma of the uterus, 318.

Krusen, Wilmer. Ovarian org-ano-therapy, 213.

Lazear (Jesse William) Memorial, 215.

Le Count, E. R. The genesis of carcinoma of the Fallopian
tube in hyperplastic salpingitis, with report of a case and a
table of twenty-one reported eases, 55.

Leonard, C. L. The advances made in medical and surgical
diagno.sis by the Riintgen method, 363.

Lewis, W. H. Observations on the pectoralis major muscle in
man, 172.

Life history of drepanidium, 300.

Lipo-myoma of the uterus, 318.

Long, Margaret. On the development of the nuclei pontis
during the second and third months of embryonic life, 123.

Long-cope, W. T. Tuberculosis of the aorta, 27.

L3'mphatic gland, human, blood-vessels of, 177.

Lymphatics in the liver, origin of, 146.

MacCallum, J. B. Development of the pig's intestines, 102.

MacCallum, W. G. Pendulous tubercles in the peritoneum, 293.

Mall, F. P. Note on the basement membranes of the tubules
of the kidney, 133; — On the development of the human
diaphragm, 158; — On the origin of the lymphatics in the liver,
146.

Marshall, H. T. Exhibition of pathological specimens: Vege-
tative endocarditis, cystic kidney, carcinoma of gall-bladder,
22.

McCrae, Thomas. Cirrhosis of the stomach, 25; — Exhiliition of
medical cases, 261.

Measurement of the external urethral orifice, 251.

Medical cases, exhibition of, 220, 261, 264-265, 296.

Medicine and doctors of Horace, 233.

Melius, E. L. Bilateral relations of the cerebral cortex, lOS.

Menstruation, normal, and some of the factors modifying- it,
178.

Microtome, new carbon-dioxide freezing-, 112.

Miller, G. B. Measurement of the external urethral orifice,
251; — Report of gynecological cases, 23.

Mitchell. J. F. Abdominal tumor containing a dermoid cyst,
25; — Exhibition of surgical cases, 17, 218.

Model of the nucleus dentatus of the cerebellum and its acces-
sory nuclei, 151.

Mosher, C. D. Abstract: The frequency of gall-stones in the
United States, 253; — Normal menstruation and some of the
factors modifying it, 178.

Musgrave, W. E., and Strong-, R. P. Preliminary note of a
case of infection with balantidium coli (Stein), 31.

Myers, W., and Durham, H. E. Abstract of interim report on
yellow fever by the Yellow Fever Commission of the Liver-
pool School of Tropical Medicine, 48; — The life history of
drepanidium, 300.

Neuritis, arsenical, case of, 221.

New carl)on-dioxide freezing microtome, 112.

Normal menstruation and some of the factors modifying it,
178.

Note on the basement membranes of the tubules of the kidney,
133.

Notes and news, 28.

Notes on aerobic spore-bearing bacilli, 13.

Notes on cervical ribs, 114.

Notes on new books, 29, 50. 189, 223, 265, 301, 372: Abbott, A. C,
The hygiene of transmissible diseases: their causation, modes
of dissemination and methods of prevention, 301; — Abrams,
A., Diseases of the heart: Their diagnosis and treatment,
230; — American Surgical Association, transactions of, 53; —
American year-book of medicine and surgery for 1901, 225; —
Anders, J. M., A text-book of the practice of medicine, 30; —
Beck, Carl, Fractures. 50; — Bishop, E. S., Uterine fibromyo-
mata, their pathology, diagnosis and treatment, 265; — Boas,
I., Diseases of the intestine, 377; — Bohm, A. A., and von

380

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 139.

Davidoff, N., A text-book of histology, 189; — Bracken, H. M.,
Disinfection and disinfectants, 50; — Biirdett, Sir Henry, Bur-
dett's hospitals and charities, lUOl, 301; — Burrell, H. L.,
Councilman, W. T., and Withington, C. F., Medical and sur-
gical reports of the Boston City Hospital, 230; — Butler, G. K.,
Diagnostics of internal medicine, 377; — Butlin, H. T., and
Spencer, W. C, Diseases of the tongue, 227; — Davis, E. P.,
Obstetric and gynecologic nursing, 376; — Dorlaud, W. A. N.,
The American illustrated medical dictionary, 303; — Eich-
horst, H., A text-book of the practice of medicine, 375; —
Fenwick, E. H., (Jolden rules of surgical practice, 223; —
Fischer, L., Infant-feeding in its relation to health and
disease, 370; — Fothergill, W. E., Golden rules of obstetric
practice, 223;— Friedrich, E. P., Khinology, laryngology and
otology, and their significance in general medicine, 51; —
Grandin, E. H., A text-book on practical obstetrics, 376; —
Golebiewski, E., Atlas and epitome of diseases caiised by
accidents, 53; — Haab, O., Atlas and epitome of ophthal-
moscopy and ophthalmoscopic diagnosis, 266; — Hale, I. W.,
Golden rules of iJhysiology, 223; — Hartridge, G., Golden rules
of ophthalmic practice, 223; — Hatfield, M. P., The acute in-
fectious diseases of childhood, 376; — Hectorn, L., Atlas and
epitome of special pathologic histology, 30; — Howell, W. H.,
An American text-book of physiology, 52; An American text-
book of physiology (vol. ii), 224; — ^Jackson, Edward, Essen-
tials of refraction and diseases of the eye, 301; A manual of
the diagnosis and treatment of the diseases of the e3-e, 51; —
Jacoby, G. W., A system of physiologic therapeutics, vol. i,
268; vol. ii, 303; — Jakob, Christfried, Atlas of the nervous
system, 302; — Jullien, L., Libertinism and marriage, 375; —
Keyser, W. W., A medico-legal manual, 225; — Kyle, D. B.,
Diseases of the nose and throat, 267; — Lakeside Hospital,
Cleveland, clinical and pathological papers from, 377; —
Leroy, L., Essentials of histology, 223; — Levy, E., and Klemp-
erer, F., Elements of clinical bacteriology for physicians
and students, 53; — Lowder, W. L., A pilgrimage; or, the sun-
shine and shadows of the physician, 226; — Lydstou, G. F.,
Panama and the Sierras: A doctor's wander days, 51; —
Manson, P., Tropical diseases: A manual of the diseases of
warm climates, 226; — Martin, P., Lehrbuch der Anatomic der
Haustiere mit besonderer Beriicksichtigung des Pferdes, 189;
— Massachusetts State Board of Health, thirty-first annual
report of, 227; — McFarland, J., A text-book upon the patho-
genic bacteria, for students of medicine and physicians, 223;
— Medical annual: A year-book of treatment and practition-
er's index, 226; — Kew York Pathological Society, proceed-
ings for the years 1899 and 1900, 375; — Osier, William, The
principles and practice of medicine, designed for the use of
practitioners and students of medicine, 372; — Osier, William,
and McCrae, Thomas, Cancer of the stomach: A clinical
study, 29; — Packard, F. E., The history of medicine in the
United States: A collection of facts and documents relating
to the history of medical science in this country from the
earliest English colonization to the year 1800, with a supple-
mentary chapter on the discovery of anaesthesia, 373; —
Powell, W. M., Essentials of the diseases of children, 267;
Saunders' pocket medical formulary, etc., 53; — Kobb, I. H.,
Nursing ethics for hospital and private use, 226; — Roger, G.
H., Introduction to the study of medicine, 229; — Sabin, F. E.,
An atlas of the medulla and midbrain, 267; — Sajous's annual
and analytical cyclopjedia of practical medicine: Vol. vi.
Diseases of the rectum and anus to zinc, 376; — Salinger, J. L.,
and Kalteyer, F. J., Modem medicine, 52; — Scudder, C. L., The
treatment of fractures, 50; Second edition, 375; — Senn, N.,
Practical surgery: A work for the general practitioner, 301;
Principles of surgery, 302; — Shoemaker, J. V., Students' edi-

tion, a practical treatise of materia mediea and therapeutics,
with special reference to the clinical application of drugs,
267; — Spalteholz, \V., Hand atlas of human anatomy, 189; —
Stengel, Alfred, A text-book of pathology, 51; — Tiffany, F. B.,
-Vnomalies of refraction and of the muscles of the eye, 268;
—Treves, F., The tale of a field hospital, 225;— Tyson, J.,
Practice of medicine: A text-book for practitioners and
students, with special reference to diagnosis and treatment,
229; — Wain Wright, J. W., Urinary diagnosis and treatment,
225;— Waldo, F. J., Golden rules of hygiene, 301;— Walsh, D.,
Golden rules of skin practice, 225.

Nuclei pontis, development of, during the second and third
months of embryonic life, 123.

Nucleus dentatus of the cerebellum and its accessory nuclei,
model of, 151.

Observations on the pectoralis major muscle in man, 172.

On a family form of recurring epistaxis, associated with
multiple telangiectases of the skin and mucous membranes,
333.

On the behavior of epineiihrin to Fehling's solution and other
characteristics of this substance, 337.

OiJerating outfit, portable, 206.

Opie, E. L. Diabetes mellitus associated with hyaline degen-
eration of the islands of Langerhans of the pancreas, 263;
The etiology of acute hemorrhagic pancreatitis, 182; Healed
amoebic abscess of the liver, and amoebic abscess of the
lung. Exhibition of specimens, 219; The relation of chole-
lithiasis to disease of the pancreas and to fat-necrosis, 19.

Opie, E. L., and Bassett, V. H. Typhoid infection without
lesion of the intestine. A case of hemorrhagic typhoid fever
with atypical intestinal lesions, 198.

Origin of the lymphatics in the liver, 146.

Osier, W. Congenital absence of the abdominal muscles, with
distended and hypertrophied urinary bladder, 331; — On a
family form of recurring epistaxis, associated with multiple
telangiectases of the skin and mucous membranes, 333; —
Exhibition of medical cases, 296 — Exhibition of medical cases:
On hemorrhage in chronic jaundice; Typhoid spine, 264-265; —
Case of asthma with cyanosis, extensive purpura, painful
muscles, and eosinophilia, 17; — Exhibition of medical cases:
Chronic jaundice with xanthoma multiplex, 220.

Osteitis deformans with report of a case, 343.

Osteoma of external auditory canal, exhibition of a case of,
219.

Ovarian organotherapy, 213.

Pancreatitis, acute, two cases of, 26.

Pancreatitis, acute hemorrhagic, etiology of, 1S2.

Pancreatitis, acute hemorrhagic, retrojection of bile into the
pancreas, a cause of, 179.

Pathological report upon a fatal case of enteritis with anaemia
caused by uncinaria duodenalis, 366.

Pathological specimens, exhibition of, 22.

Pectoralis major muscle in man, observations on, 172.

Pelvic inflammatory masses, removal of, by the abdomen after
bisection of the uterus, 1.

Pendulous tubercles in the peritoneum, 293.

Piatt, W. B. Eeport of cases from the Garrett Hospital for
Children, 18.

Porter, O. J. Observations upon smallpox, 298.

Pott's disease, hyperextension as an essential in the correc-
tion of the deformity of, with the presentation of original
methods, 32.

Preliminary note of a case of infection with Balantidium coli
(Stein), 31.

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

381

Preservation of anatomical material in America by means of
cold storage, 117.

Prevention of tuberculous diseases in infancy and childhood,
271.

Proceedings of the Johns Hopkins Hospital Medical Society,
17, 216, 261, 295.

Pulmonary tuberculosis in Baltimore, 288.

Randolph, E. L. Exhibition of a case of osteoma of external
auditory canal, 219.

Reconstruction by means of wax plates as used in the anat-
omical laboratory of the Johns Hopkins University, Horn's
method of, 148.

Relation of cholelithiasis to disease of the pancreas and to
fat-necrosis, 19.

Remarkable cases of hereditary anchyloses, or absence of
various phalangeal joints with defects of the little and ring
fingers, 129.

Removal of pelvic inflammatory masses by the abdomen after
bisection of the uterus, 1.

Report of cases from the Garrett Hospital for Children, IS.

Report of a case of carcinoma diagnosed by means of para-
centesis abdominis; with some remarks on the diagnostic
value of examinations of serous effusions, 310.

Report of a case of fulminating hemorrhagic infection due to
an organism of the bacillus mucosus capsulatus group, 45.

Report upon B. mortiferus, 216.

Respiratory exercises in the prevention and treatment of
pulmonary tuberculosis, 282.

Eetrojection of bile into the pancreas, a cause of acute hem-
orrhagic pancreatitis, 179.

Rontgen method, advances made in medical and surgical diag-
nosis by the, 363.

Sabin, F. A case of arsenical neuritis, 221; — A case of arterial
disease, possibly periarteritis nodosa, 195.

Saranac Laboratory for the study of tuberculosis, history and
work of, 271.

Secondary syphilitic eruption, 21.

Smallpox, observations upon, 298.

Steiner, W. R. Report of a case of carcinoma diagnosed by
means of paracentesis abdominis; with some remarks on the
diagnostic value of examinations of serous efEusion.s, 310.

Stieren, E. Tubercular dacryoadenitis and conjunctivitis, con-
taining the report of a probable case ending in spontaneous
recovery and a review of the previous literature on tuber-
cular dacryoadenitis, 349.

Stokes, \V. E. Ulcer of the stomach caused by the diphtheria
bacillus, 209.

Strong, E. P., and Musgrave, W. E. Preliminary note of a case
of infection with Balantidium coli (Stein), 31.

Study of anatomy, 87.

Sudler, M. T. The architecture of the gall-bladder, 12(i.

Summaries or titles of papers by members of the Hospital and
Medical School staff appearing elsewhere than in the Bul-
letin, 16, 49, 80, 221, 295: Bardeen, C. E., Casto-vcrtebral varia-
tion in man, SO; The function of the brain in planaria
maculata, 221; — Bardeen, C. R., and Elting, A. W., A sta-
tistical study of variations in the formation and position of
the lumbo-sacral plexus in man, 221; — Barker, L. 1''., On the
importance of pathological and bacteriological laboratories
in connection with hospitals for the insane, 221; The so-
called cardiac neuroses: Classification, etiology, pathology,

221; — Berkley, H. J., Clinical cases: VII. The pathology of
chronic alcoholism, SO; — Block, E. Bates, Enchondroma-like
formations in the femur, following osteomyelitis, 221; —
Bloodgood, J. C, Blood examinations as an aid to surgical
diagnosis, 222; — Brown, T. R., A review of some of the
recent work on the physiology and pathology of the
blood, 16, 222; Notes on the blood and vesicle cells
in Dr. Smith's case of epidermolysis bullosa, 222; On the
relation between the variety of micro-organisms and the
composition of stone in calculous pyelonephritis, 222; The
prospect in the treatment of lobar pneumonia, 222; Urinary
hyperacidity: A consideration of cases with symptoms sug-
gestive of cystitis, but with no infection, due to this cause,
222; — Cary, Charles, and Lyon, I. P., Primary echinococcus
cysts of the pleura. Report of a case of primary exogenous
echinococcus cysts of the pleura, showing hyaline degenera-
tion of the cuticle without lamellation, with notes from the
literature, 49; — Cullen, T. S., The cause of cancer, 222; —
Cullen, T. S., and Goldsborough, B. W., A rare form of extra-
uterine pregnancy, 222; — Cushing, H., Concerning prompt
surgical intervention for intestinal perforation in typhoid
fever, with the relation of a case, 222; Sur la Laparotomie
Exploratrice Precoce dans la Perforation Intestinale au
Cours de la Fievre Typhoide, 222; — ^Butcher, Adelaide, Where
the danger lies in tuberculosis, 16; — Flexner, S., Etiology of
dysentery, 222; Experimental pancreatitis, 222; Nature and
distribution of the new tissue in cirrhosis of the liver, 16;
Nature and distribution of the new tissue in cirrhosis of
the liver (preliminary communication), 80; The etiology of
tropical dysentery, 222; — Ford, W. W., Obstructive biliary
cirrhosis, 222; On the bacteriology of normal organs, 222;
Variation of the properties of the colon bacillus, isolated
from man, 222; Venous thrombosis in heart disease, 16; —
Futcher, T. B., Syphilitic fever, with a report of three cases,
222, 295;— Gwyn, N. B., The disinfection of infected typhoid
urines, 222; — Harris, N., A preliminary report upon a hitherto
undescribed pathogenic anaerobic bacillus, 222; — Harrison,
E. G., Ueber die Histogenese des peripheren Nervensystems
bei Salmo salar, 222; — Hewlett, A. W., The superficial glands
of the oesophagus, 222; — Hunner, G. L., and Lyon, I. P., Men-
suration and capacity of the female bladder: Observations
on the female bladder dilated by atmospheric pressure in
the knee-breast posture, 49; — Jacobs, H. B., A short account
of the recent International Medical Congress in Paris, 222;
Four cases of sporadic cretinism, 222; — Kelly, H. A., A rapid
and simple operation for gall-stones found by exploring the
abdomen in the course of a lower abdominal operation, 80;
How to deal with the vermiform appendix: Some forms of
complicated appendicitis, 222; Jules Lamaire: The first to
recognize the true nature of wound infection and inflamma-
tion, and the first to use carbolic acid in medicine and
surgerj-, 222; — Knox, J. H. M., Compression of the ureters
by myomata uteri, 16; — Lyon, I. P., On peculiar condition of
the hair, 49; Tj-pes of normal and morbid blood, 49; — Lyon,
I. P., and Wright, A. B., An inquiry into the existence of
autochthonous malaria in Buffalo and its environs: Prelim-
inary report on species of mosquitoes and blood-examina-
tions, 49; — McCrae, T., Abdominal pain in typhoid fever, 222; —
Miller, G. B., The streptococcus pyogenes in gynecologic
di.seases, 222; — Nutting, M. A., The preliminary education of
nurses, 222; — Opie, E. L., On the relation of chronic intes-
tinal pancreatitis to the islands of Langerhans and to dia-
betes mellitus, 223; The relation of diabetes niellitus to
lesions of the pancreas: Hyaline degeneration of the islands

382

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

of Langerhans, 223; The relation of cholelithiasis to disease
of the pancreas and to fat-necrosis, 222; — Osier, W., A
plea for the more careful study of the symptoms of per-
foration in typhoid fever with a view to early operation, 223;
An address on John Locke as a physician, 80; Hemorrhage in
chronic jaundice, 223; On perforation and perforative peri-
tonitis in typhoid fever, 223; On the study of tuberculosis,
16; The medical aspects of carcinoma of the breast, with a
note on the spontaneous disappearance of secondary
growths, 223; The natural method of teaching the study of
medicine, 223; The study of internal medicine, 223; — Peters,
L., Resection of the pendulous, fat abdominal wall in cases
of extreme obesity, 223; — Pleasants, J. Hall, A case of
acromegaly in a negro associated with a low grade of
giantism, 16; — Randolph, R. L., Ossification of the choroid
leads to the identification of the body in an insurance case.
16; — Reik, H. O., The value of formaldehyde in the treatment
of suppurative otitis media, 223; — Robb, H.. Remarks upon
the post-operative treatment, with especial reference to the
drugs employed in 114 consecutive, unselected abdominal
sections without death, 16; The treatment of nausea and
vomiting following anaesthesia after abdominal operations,
223; — Schenck, B. E., Four cases of calculi impacted in the
ureter: Nephro-ureterectomy, abdominal uretero-lithotomy.
vaginal uretero-lithotomy, 223; — Steiner, W. R.. Dermatomy-
osites, with report of a case which also presented a rare
muscle anomaly, but once described in man, 223; — Thayer,
AV. S., Observations on the blood in typhoid fever, 16; —
Theobald, S., The evolution of the ophthalmoscope and what
it has done for medicine. 223; — VerhoefE. F. H., A case of
noma of the auricles, due to the streptococcus pyogenes,
and its bearing on the etiology of noma in general, 29.5; The
theory of the vicarious fovea erroneous, 295; — ^AValker, G..
Curetting the urethra in the treatment of chronic posterior
urethritis. 223; Tuberculosis of the vesiculae seminales. tes-
tes and prostate: complete excision of right side, incision
and curetting on left side: cured, 223; — Welch, W. H., Dis-
tribution of bacillus aerogenes capsulatus (Bacillus Welclii.
Migula), 223; — Whitridge, A. H., Report of a case of tetanus
with recovery, 16; The importance of instruction in medical
schools upon the modification of milk for prescription feed-
ing, 16; — Young, H. H., An operating-table for office work,
223; Ueber ein neues Verfahren zur Exstirpation der Samen-
blasen und der Vasa deferentia, nebst Bericht iiber zwei
Falle, 223.

Surgical cases, exhibition of, 17, 218.

Tails in man, with a description of the case reported by Dr.
Watson, 96.

Taylor, E. T. Hyperextension as an essential in the correc-
tion of the deformity of Pott's disease, with the presenta-
tion of original methods, 32.

Taylor, W. J. Volvulus of Meckel's diverticulum, with re-
covery after operation, 326.

Tendon transplantation, 261.

Thomas, H. M. Chorea with embolism of central artery of the
retina. A short review of the embolic theory of chorea, 321.

Tinker, M. B. The first nephrectomy and the first cholecysto-
tomy, with a sketch of the lives of Doctors Erastus B. Wol-
cott and John S. Bobbs, 247.

Trudeau, E. L. The history and work of the Sarauac Labora-
tory for the study of tuberculosis, 271.

Tubercles, pendulous, in the peritoneum, 293.

Tubercular dacryoadenitis and conjunctivitis, containing the
report of a probable case ending in spontaneous recovery
and a review of the previous literature on tubercular dacryo-
adenitis, 349.

Tuberculosis of the aorta, 27.

Tuberculosis, pulmonary, respiratory exercises in the preven-
tion and treatment of, 282.

Tuberculous diseases in infancy and childhood, prevention of,
271.

Tumor, abdominal, containing a dermoid cyst. 25.

Two cases of acute pancreatitis, 26.

Two examples of Bence Jones' albumosuria associated with
multiple myeloma, 38.

Typhoid bacilli in the blood, frequency of, 203.

Tj'phoid infection without lesion of the intestine. A case of
hemorrhagic typhoid fever with atypical intestinal lesions,
198.

Typhoid spine, 265.

Ulcer of the stomach caused by the diphtheria bacillus, 209.

LTse of the material of the dissecting room for scientific pur-
poses, 155.

Volvulus of Meckel's diverticulum, with recovery after opera-
tion, 326.

Walker, George. An experimental study concerning the rela-
tion which the prostate gland bears to the fecundative power
of the spermatic fluid, 77; Remarkable eases of hereditary
anchyloses, or absence of various phalangeal joints with
defects of the little and ring fingers, 129.

Warfield, L. M. Carcinoma of the male breast, 305.

Welch, W. H. Introductory note to Drs. Durham and Myers's
report, 48.

Yates, J. L. Pathological report upon a fatal case of enteritis
with ansemia caused by uncinaria duodenalis, 366.

Yellow fever, abstract of interim report on, by the Yellow
Fever Commission of the Liverpool School of Tropical Medi-
cine, 48.

ILLUSTRATIONS.

1. Removal of pelvic inflammatory masses (Plates I and II,

Figs. 1-6), 2.

2. Intrinsic blood-vessels of the kidney (Plates III-X, Figs.

1-11), 12-13.

3. Tuberculosis of the aorta (Fig. 1), 27.

4. Hjperextension as an essential in the correction of the

deformity of Pott's disease (Plates XI-XIV, Figs. 1-18),
36-37.

5. Carcinoma of the Fallopian tube in hyperplastic salpingitis

(Plates XV and XVI, Figs. 1-7), 62.

6. Occurrence of tails in man (Plates XVII and XVIII, Figs.

1-6), 100.

7. Development of the pig's intestine (Plates XIX and XX,

Figs. 1-17), lOS; (Fig. 18), 105; (Fig. 19), 107.
S. Bilateral relations of the cerebral cortex (Figs. 1-7), 110-

114.
9. A new carbon-dioxide freezing microtome (Figs. 1-2), 113.

10. Notes on cervical ribs (Figs. 1-2), 114-115.

11. Preservation of anatomical material in America by means

of cold storage (Figs. 1-7), 118-121.

12. Development of the nuclei pontis in the second and third

months of embryonic life (Plates XXI-XXIV, Figs. 1-13),
124-125.

13. Architecture of the gall-bladder (Plates XXV and XXVI,

Figs. 1-7), 128.

December, 1901.]

JOHNS HOPKINS HOSPITAL BULLETIN.

383

14. Hereditary anchyloses, or absence of various phalangeal

joints (Plates XXVII and XXVIH, Figs. 1-4), 132-133.

15. Note on the basement membranes of the tubules of the

kidney (Figs. 1-3), 134-135.

16. Study of the generative tract in termites (Figs. 1-2), 135-136.

17. Composite study of the axillary artery in man (Figs. 1-7),

137-140.

18. Origin of the lymphatics in the liver (Fig. 1), 147.

19. Born's method of reconstruction by means of wax plates,

etc. (Fig. 1), 149.

20. Model of the nucleus dentatus of the cerebellum and its

accessory nuclei (Fig. 1), 152; (Plate XXIX, Pigs. 2-4),

154; (Plate XXX, Figs. 5-7), 155.
Use of the material of the dissecting-room for scientific

purposes (Figs. 1-4), 155-158.
Development of the human diaphragm (Figs. 1-45), 160-171.

23. Observations on the pectoralis major muscle in man (Figs.

1-10), 172-177.

24. Blood-vessels of the human lymphatic gland (Plate XXXI,

Figs. 1-6), 178.

25. A portable operating outfit (Figs. 1-4), 207-208.

26. Ulcer of the stomach caused by the diphtheria bacillus

(Fig. 1), 211.

27. Erastus B. Wolcott, 248.

28. John S. Bobbs, 250.

21.

22,

29. Measurement of the external urethral orifice (Figs. 1-2),

251-252.

30. Saranac laboratory for the study of tuberculosis. Built in

1894. Interior of Saranac laboratory for the study of
tuberculosis (Plate XXXII), 272.

31. Elevated non-breakable spittoon; Individual pocket flask,

279.

32. Respiratory exercises in the prevention and treatment of

pulmonary diseases (Figs. 1-4), 284-285.

33. Charts I-V accompanying Dr. Cushing's article (Plates

XXXIII-XXXIV), 290-291.

34. Pendulous tubercles in the peritoneum (Plate XXXV), 294.

35. Case of carcinoma diagnosed by means of paracentesis

abdominis (Plate XXXVI), 314.

36. Primary adeno-carcinoma of the Fallopian tubes (Plate

XXXVII, Figs. 1-3), 316.

37. Lipo-myoma of the uterus (Plate XXXVIII, Figs. 1-2), 318.

38. Photograph of Meckel's diverticulum, natural size, 327.

39. Congenital absence of the abdominal muscles, with dis-

tended and hypertropliied urinary bladder (Figs. 1-2),
332.

40. Osteitis deformans with report of a case (Plate XXXIX,

Figs. 1-2); Skiagraph of left femur, 348.

41. Bilateral tubercular dacryoadenitis, 351.

42. Advances made in medical and surgical diagnosis by the

Eontgen method (Plate XL, Figs. 1-10), 364.

HOSPITAL STAFF DECEMBER 1, 1901.

Superintendent :
HENRY M. HURD, M. D.

Phtsician-in-Chief :
WILLIAM OSLER, M. D.

Surgeon-in-Chief :
WILLIAM S. HALSTED, M. D.

Gynecologist-in-Chief :
HOWARD A. KELLY, M. D.

OBSTETKICIAN-IN-CniEF ;

J. WniTRIDGE WILLIAMS, M. D.

Pathologist:
WILLIAM n. WELCH, M. D.

Associates in Surgery :
J. M. T. FINNEY, M. D., J, C. BLOODGOOD, M. D.

Associate in Medicine:
W. S. THAYER, M. D.

Associates in Gynecology :
W. W. RUSSELL, M. D., T. S. CULLEN, M. B.

Resident Physician :
T. McCRAE, M. B.

Assistant Resident Physicians :
R. I. COLE, M. D., C. P. EMERSON, M. D.

Resident Surgeon :
J. F. MITCHELL, M. D.

Assistant Resident Surgeons:
R. H. FOLLIS, M. D., M. B. TINKER, M. D.,

W. F. M. SOWERS, M. D.

Resident Gynecologist :
G. L. HUNNER, M. D.

Assistant Resident Gynecologists :
B. R. SCHENCK, M. D.,* J. A. SAMPSON, M. D.

C. F. BURNAM, M. D.*

Resident Obstetrician:
F. W. LYNCH, M. D.

Resident Pathologist:
W. G. MacCALLUM, M. D.

Assistant Resident Pathologists :
E. L. OPIE, M. D., W. B. JOHNSTON, M. D.

House Medical Officers :

F. H. BAETJER, M. D.,
T. R. BOGGS, M. D.,
J. I. BUTLER, M. D.,t
R. F. HASTREITER, M. D.,
J. M. HITZROT, M. D.,
J. M. SLEMONS, M. D.,
L. M. WARFIELD, M. D.,

J. M. BERRY, M. D.,
C. H. BUNTING, M. D.,
H. A. FOWLER, M. D,,
J. H, HATHAWAY, M. D.,
M. J. RUBEL, M. D.,
C. N. SPRATT, M. D.,
S. H. WATTS, M. D.

Externe :
C. K. WINNE, M. D.

*Absent on leave.

tActing.

384

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 129.

PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.

THE JOHNS HOPKINS HOSPITAL REPORTS.

Volume I. 423 pages, 99 plates.

Volume II. 570 pages, with 28 plates and figures.

Volume III. 766 pages, with 69 plates and figures.

Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

By William Osler, M. D.. with additional papers by W. S. Tuaver, M. l'.,
and J. Hbwetson. M. D.

Report in Nearoloey.

Dementia Paralytica In the Negro Itace; Studies In the Histology of i"
Liver; The Intrinsic rulmonary Neivea In Mammalia; The Intrli> "
Nerve Supply of the Cai-di.ic Ventricles in Certain Vertebrates: '■ ^
Intrinsic Nerves of the Submaxillary Gland of Af?(.s muftculuti: 'iMo
Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elemej-.s
of the Pituitary Gland. By Henrt J. Berkley, M. D.

Report in Snrgery.

The Results of Oneratlons for the Cure of Cancer of the Breast, fr- 'n
June, 1889, to January, 1894. By W. S. Halsted, M. D.

Report In Gynecologry.

Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Ser ic
Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M •'.

Report In Patliologry.

Dedduoma Malignum. By J. Whitridqb Williaub, M. D.

Volume V. 480 pages, with 32 charts and illustrations.

CONTENTS:

The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewet-

SON, M. D.
A Study of some Fatal Cases of Malaria. By Lewellts F. Barker, M. E.

Studies In Typlioid Fever.

By William Osler, M. D., with additional papers by G. Blumeb, M. D.,
Simon Flexner, M. D., Walter Heed, M. D., and H. C. Parsons, M. D.

Volume VI. 414 pages, with 79 plates and figures.

Report In Nenroloery.

Studies on the Lesions produced by the Action of Certain Poisons on the
Cortical Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.

Introductory.— Recent Literature on the Pathology of Diseases of the Brain
by tne Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Erper
Imental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alco-
hol). 2. Experimental Lesions produced by Acute Alcoholic Polsonin?
(Ethyl Alcohol): Part IL— Serum Poisoning.— Experimental Lesions in-
duced by the Action of the Dog's Serum on the Cortical Nerve Cell;
Part III.— Ricin Poisoning.— Experimental Lesions induced by Acute
Ricin Poisoning. 2. Experimental Lesions induced bv Chronic Ricin
Poisoning: Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical
Nerve Ceil produced by the Toxine of Experimental Rabies: Part V.—
Pathological Alterations In the Nuclei and Nucleoli of Nerve Cells from
the Effects of Alcohol and Rlcln Intoxication; Nerve Fibre Terminal
Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Pattioloey.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By

Thomas S. Collen, M. B.
Pregnancy in a RuJimentary Uterine Horn. Rupture. Death, Probable

Migration of Ovum and Spermatozoa. By Thomas S. Cullen , M. B. anil

G. I/. WiLKINS. M. D.

Adeno-Myoma Uteri Ditfusum Benlgnum. By Thomas S. Ccllen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of

Infants. By William D. Booker. M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D.

Volume VII. 537 pages with illustrations.

I. A Critical Review of Seventeen Hundred Cases of Abdominal Section
from the standpoint of Intraperitoneal Drainage. By J. G. Clark,
M. D.

n. The BtlolOCT and Structure of true Vaginal Cysts. By James Ernest
Stokes. M. D,

A Review of the Pathology of Superficial Burns, with a Contribution
to our Knowledge of the Pathological Changes in the Organs lu cases
of rapidly fatal burns. By Charles Russell Bardeen, M. D.
IV. The Origin, Growth and Fate of the Corpus Luteum. By J. G.
Clark, if. D.

V. The Results of Operations for the Cure of Inguinal Hernia. By
Joseph C. Bloodooop, M. D.

Ill

Volume VIII. 552 pages with illustrations.

On the role of Insects, Arachnids, and Myrlapods as carriers in the spread
of Bacterial and Parasitic Diseases of Man and Animals. By Georob
H. F. Ndttall, M. D., Ph. D.

Stndies in Typlioid Fever.

By William Osler. M. D., with additional papers by J. M. T. Finnet. M. D.,
S. Flexner, M. D.. L P. Lyon, M. D.. L. P. Hamburger, M. D., H. W.
CnsHiNO. M. D.. J. F. Mitchell, M. D., c. N. n. Camac. M. D.. N. B. Gwtn,
M. 1)., Charles P. Emekbon, M.D., H. II. Yuung, M. D., and W.S. Thayer, M.D

Volume IX. 1060 pages, 66 plates and 210 other Illus-
trations.

Contribntions to the Science of Alediclne.

Dedicated by his Pupils to William Henry Weilch, on the twenty-flfth anniversary
of bis Doctorate. This volume contains 38 separate papers.

Volume X. (Nos. 1-2 now ready.)

structure of tlie Malarial ParasileB. Plate I. Py Jessk W. Lazkak. M. D.

The Eacteriolosy of f'ystltiB, Pyelitis and PyelonephrUle in Women, with a Consideration,
of the Accessory Etiological Factors in these Conditions, and of the Various Chemical
and Microscopical Questions Involved. By Tuomas K. Brown. M. 1).

Cases of Infection with Stroniryloides Intestinalis. (First Keported Occurrence In North
America.) Plates II and III. By KicriABD P. Strong, M.D. Price in paper, ^1.50.

The set of ten volniiies ^vill 1»e sold for fifty-five dollars, net.
Volumes I and II 'n-ill not be Nold separately. Volumes III,
IV, V, VI, A II, AIII and X will be sold for five dollars, net,
each.. Volume IX tvIII be sold for ten dollars, net.

SEPARATE MONOGRAPHS REPRINTED FROM THE JOHNS
HOPKINS HOSPITAL REPORTS.

Stndies in Derniatolog^y. By T. C. Gilchrist, M. D., and Emmet Rixford,
M. D. 1 vnlnnie of 164 pages and 41 full-page plates. Price, bound in paper, $:i.OO.

Tlie Malarial Fevers of Haltimore. By W. S. Thayer, M. D., and J.
Hewetson, M. D. And A Study of some Fatal Cases of Malaria.

By Lewellys F. Barker, M. B. 1 volume of 28u pages. Price, bound in paper,

$2.7;-..
Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D.

1 volume of 150 pages with 4 full-page lithographs. Price, in paper, $2.00.
Studies in Typlioid Fever, 1, II, III. By William Osler, M. D., and

others. Exrracled from Vols. IV. V and VIII of the Johns Hopkins Hospital Report

1 volume of 8S1 pages. Price, bound in cloth, $5.00.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

The Hospital Bulletin contains details of hospital and dispensary practice;
abstracts of papers read and other proceedings of the Medical Society of tlie Hospital,
reports of lectures, and other matters of general interest in connection with the
work of the Hospital. It is issued monthly. \oIunie XII is now completed. The
subscription price is $1.00 per year. The set of twelve volumes will be sold tor
?'J3.(0.

Ordera should be addressed to

Tlie Johns Hopkins Press, Baltimore, Md.

The Johns HnpMna Hospital BuUcliyis are 'ssxted monlhly. They are printed by THE FRIEDENWALD CO., Baltimore. SingU copies may he procured from
Messrs. CUSBINO A CO. and the BALTIMORE NEWS CO., Baltimore. Subscriptions, $1.00 a year, may he add/ressed to the publishers, THE JOHNS HOPKINS
PRESS, BALTIMORE, single copies will be sent by mail for fifteen cents each. \

BINDING SECT. MAY 19

The Johns Hopkins medical
j ournal

31
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